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Wºº.
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e-et-, 2-
LOCAL AND REGIONAL
ANESTHESIA
With Chapters on Spinal, Epidural, Paravertebral, and Para-
sacral Analgesia, and on other Applications of Local and
Regional Anesthesia to the Surgery of the Eye, Ear, Nose and
Throat, and to Dental Practice
BY
CARROLL W: ALLEN. M. D.
INSTRUCTOR IN CLINICAL SURGERY AT THE TULANE UNIVERSITY OF LOUISIANA, NEW
ORLEANS; LECTURER AND INSTRUCTOR IN GENITO-URINARY AND RECTAL DISEASES AT
THE NEW ORLEANS POLYCLINIC; VISITING SURGEON TO THE CHARITY HOSPITAL
WITH AN INTRODUCTION BY
R U DO L PH M ATAS, M. D.
PROFESSOR OF GENERAL AND CLINICAL SURGERY AT THE TULANE UNIVERSITY OF
LOUISIANA, NEW ORLEANS, ETC.
ILLUSTRATED
PHILADELPHIA AND LONDON
W. B. SAUNDERs com PANY
1914
Copyright, 1914, by W. B. Saunders Company
PRINTED IN AMERICA
PRE88 OF
W. B. 8AUNDERS COMPANY
PHILADELPHIA
TO
PROFESSOR RUDOLPH MATAS
Surgeon, scholar, teacher; one of the pioneers in the field
of local and regional anesthesia under whose guidance
the author was initiated into surgery, whose example and
friendship prompted the conception of this work, and
whose teachings and writings have contributed many pages
of the text, this volume is gratefully dedicated.
INTRODUCTION
FOR nearly twenty years the control of pain in surgical opera-
tions by local and regional methods has been the subject of our earnest
study. As director of the surgical clinics of the College of Medicine
of the Tulane University since 1895, we began to utilize the large
clinical material at our command in the effort to diminish the indica-
tions for general narcosis, and to substitute for the immediate dangers
of chloroform, which was then the routine anesthetic in almost all
Southern clinics, the more laborious but far safer methods of peripheral
analgesia. Beginning with a purely local and peripheral technic, in
which intradermal infiltration and massive edematization with
dilute isotonic cocain solutions were chiefly utilized, in accordance
with the principles laid down by Corning, Halsted, Reclus, and
Schleich, we soon advanced from the minor work of the dispensary
to the more ambitious fields of major surgery.
In 1897 we discarded cocain and adopted beta-eucain and soon
became engrossed in the neuroregional methods' alone or combined
with massive infiltration, which rapidly expanded in every direction,
yielding the most gratifying and, at that time, almost incredible
results. The pursuit of this regional method was carried out with
so much vigor and enthusiasm that in 1900° we were able to publish
two extensive reports which reviewed the progress of our work and
* In referring to regional methods we exclude the spinal or subarachnoid method
(L. Corning, 1886–1894); Bier (1899) as a central method.
After an experience with over 3oo applications of this method with cocain and its
various substitutes, we experienced a transition from a state of great enthusiasm to one
of decided depression, having learned by hard experience and careful study of our results
that the benefits of this procedure were more apparent than real. Since then we have
restricted the application of spinal analgesia to a very circumscribed and steadily smaller
group of indications.
* “The Growing Importance and Value of Local and Regional Anesthesia in Minor
and Major Surgery,” Transaction of Louisiana State Med. Assoc., April, 1900, pp. 1-78;
“Local and Regional Anesthesia with Cocain and Other Analgesic Drugs,” Philadelphia
Med. Jour., November 3, 1900, pp. I-72.
27.2622
3
4. INTRODUCTION
that of others and gave an account of the considerable success that
we had obtained in the invasion of new territories.
By blocking the nerve-trunks at their exit from the cranial foramina,
jaws were resected, the tongue and floor of the mouth excised, and, by
a similar process, craniotomy, thyroid and laryngeal resections, ampu-
tations of the extremities, resection of joints, thoracotomies, hernias,
and the entire domain of genito-urinary, rectal, and a considerable
share of pelvic and abdominal surgery became subservient to the
new methods. In this way we were able to show in 1900 that fully
50 to 60 per cent. of the operations, which six years before would
have required a general narcosis, had become amenable to local and
regional anesthesia.
Fourteen years have elapsed since that time. Great transforma-
tions have taken place in our methods of general narcosis. Chloro-
form, which for half a century had reigned supreme as the autocrat
of the operating theater, has been practically banished from the
clinics of the South—its last stronghold. Ether by the open mask
and drop method has entirely supplanted it; and now nitrous-oxid
gas in combination with ether, alone or with oxygen, is gaining favor
steadily in our main operative and especially private clinics. The
effect of this revolution in reducing the immediate mortality of
general narcosis, and, to Some extent, in diminishing the postanes-
thetic risks, is universally recognized. However, the problem of
shock, the Secondary nausea and vomiting, the pulmonary com-
plications, embolism and thrombosis, and, above all, the degen-
erative auto-intoxications following the action of these somatic
poisons on the eliminating and other organs still remain to be
reckoned with.
On the other hand, the synthetic chemist and pharmacologist
have not been idle, and their untiring and brilliant efforts to find sub-
stitutes for the dangerous and costly cocain have given us a succes-
sion of remarkable synthetic products, such as beta-eucain, nirvanin,
alypin, stovain, anesthesin, etc., which have been successively dis-
placed by what now appears to be the nearest approach to the ideal
local analgesic—novocain.
In like manner, the genius of synthetic chemistry and the bio-
logic laboratory have found in suprarenin a less perishable substi-
tute for adrenalin, the active product directly obtained from the
gland. The advent of adrenalin and its synthetic substitutes has
marked a new era in the history of local anesthesia. By its powerful
and lasting vasoconstrictor and ischemic action it gives the operator
INTRODUCTION 5
a bloodless field, which has deserved for it the name of the “chemical
tourniquet” (Braun). Combinations of novocain and adrenalin in
various isotonic dilutions—by practically eliminating the toxicity of
the analgesic, increasing its stability, durability, and intensity—
have so expanded the technic that in the hand of an expert peripheral
analgesia may be made to encompass in its grasp almost the entire
domain of operative surgery.
>k :k :k
But with all its great achievements the art of local and regional
anesthesia is still young. Barely three decades have elapsed since
Karl Köller made his epochal demonstration of the anesthetic prop-
erties of cocain at Heidelberg in 1884, and yet, in spite of the stupen-
dous distance that we have traveled since then, the horizon of peripheral
anesthesia is ever widening and offering new opportunities for profitable
exploitation. It is still in process of development; it still offers many
difficult problems that await solution.
In dealing with major operations, its successful application de-
mands patience, time, and skill—a skill that can only be acquired
and exercised on the human cadaver by those who, being anatomists,
can alone survey the field of operation with fluoroscopic eyes. For
this reason the practice of peripheral anesthesia, especially in its
neuroregional aspects, appeals most pointedly to the young, ambi-
tious, and well-trained surgeon, who, fresh from the anatomic labora-
tory, finds here, as nowhere else, an immediate and practical applica-
tion for a knowledge that he has acquired at the cost of long nights
of vigil, labor, and thought.
In these days when exact topographic and applied anatomy is
rated somewhat at a discount, it is a source of no small gratification
for the young but well-trained man to discover that his anatomic
knowledge is a living, palpable, and productive asset. Not a thing to
be learned solely as a matter of academic culture and soon to be for-
gotten, but a practical tool to be used in unlocking his most immediate
technical problems. It is only through the aid of applied anatomy
that regional anesthesia is what it is to-day. It is for this reason that
all, or nearly all, the notable advances that have been made in its
technic have been due to the enterprise and the activities of young
surgeons. Leonard Corning, Halsted, Reclus, Schleich, Crile, Cush-
ing, Bier, Oberst, Braun, and a host of others who have laid the funda-
mentals of this work did so in their earlier professional years. It is
this same potential spirit in the young man fresh from the anatomic
and physiologic laboratories that animates their followers—the
6 INTRODUCTION
builders of the present day. Such men as Offerhaus, Härtel, Peuckert,
Hirschel, Kulenkampf, Danis, Finsterer, Läwen, and others in
Europe, not to mention a group of young Surgeons in this country
and in our own immediate surroundings—who are enriching the
foundation laid down by the masters by their contributions, based
chiefly upon anatomic and physiologic researches.
Whatever may be the limitations of regional anesthesia and the
objections that have been argued against it, no one can deny that it
has given a new impetus to anatomic teaching; that it has placed a
high valuation upon an exact anatomic training, and that in this way
it is making it less possible for the mere cutter—the “cut and tie.”
type of practitioner—to be confused with the real Surgeon. For this
reason alone it deserves the encouragement and fostering care of
every surgeon and every teacher who has at heart the higher welfare
of his science and his art.
>k :k >k
To review and summarize the evidences of progress in local and
regional analgesia; to study and analyze the copious and constantly
growing literature which is rapidly piling up to pyramidal and almost
inaccessible heights; to scrutinize the various analgesics that are born
yearly in the laboratory of the chemist, and try the methods by which
they may be utilized with special advantage in the different regions
of the body and in connection with the surgical specialties; to gauge
the value of the various technics proposed by the criterion of clinical
observation and personal experience, and, in a like manner, to judge of
their advantages and limitations in their relation to the general
narcosis, was a task which I had set to myself, and which, after an
experience of over two decades in this mode of practice, I felt might
prove profitable to the profession, if only in the interests of a useful
propaganda.
But, unfortunately, many circumstances and more urgent in-
terests directed my attention into other channels, and the time has
never come when I could sit down peacefully and calmly to the
realization of my project. Fortunately for my purpose, the seed
Sown in earlier years appears to have yielded good and seasonable
fruit. Associated with me as pupils and assistants were a group of
young men who entered into the spirit of the work with zeal and
enthusiasm. The results obtained in our clinics and exhibited in
Our reports of Igoo, and subsequently, have been made possible
largely through their faithful collaboration. Several of these have
already attained enviable reputations in our community and else- .
INTRODUCTION 7
where, as teachers and surgeons especially skilled in the methods of
local and regional anesthesia, and to all these I owe a debt of grati-
tude. Conspicuous among these is Dr. Carroll W. Allen, whose
steadfast loyalty to these methods for many years has been rewarded
by a reputation for special skill and judgment in their application
which is eminently deserved. He has assiduously cultivated the
technic in all its variations, many of which are his own, and in our
joint Services at the Charity Hospital the results obtained have
proved so satisfactory that fully 55 or 60 per cent. of the major opera-
tions in the division under his charge are performed solely by periph-
eral anesthetic procedures, exclusive of the spinal or subarachnoid
analgesias which are not included in this category. One of the best
proofs of the Success of any method of practice is the confidence it
inspires among the men of the profession and in their willingness to
have it applied to themselves. Schleich, in his “Schmerzlose Opera-
tionen,” tells us how his clinic was besieged by doctors who, needing
Surgical relief for various ailments, were anxious to be operated on by
him painlessly, but without the unconsciousness of general narcosis.
This is the experience of every operator whose reputation for skill in
local and regional methods is confirmed by his results. Dr. Allen is
no exception to this rule.
Now, returning to the book. I had almost abandoned all expecta-
tion of accomplishing this self-appointed task when Dr. Allen gener-
ously offered his collaboration. I had hoped that this valued offer
would have made the task lighter. Dr. Allen set himself seriously
and earnestly to work and gathered a large mass of material which I
found it impossible to edit with him without the sacrifice of other and
more pressing obligations, or subjecting the publishers to unwar-
ranted delays. All that I could do was to give him the full and free
use of my previous writings and original observations on this subject
and such general counsel as my experience dictated. This volume
as it stands is, therefore, the result of Dr. Allen's sole industry, thought,
and labor. My regret is that I have not been able to join forces with
him in accomplishing a task which it was my privilege to initiate even
though indirectly, and in which I have always had a deep and abiding
interest. Without having had an opportunity to revise the text or
to read it thoroughly—through no fault of Dr. Allen or lack of willing-
ness on my part—I am satisfied, by many years of professional and
friendly association with the author, that the methods and teachings
expounded for the last twenty years in the Surgical clinics of the
Tulane University will not only be well represented, but will be
8 INTRODUCTION
strengthened, and thereby diffused over a greater and growing
a ſea.
If Dr. Allen's book will only encourage others to follow his ex-
ample, and stimulate his contemporaries, and especially the young
Surgeons of the rising generation, to cultivate the “qualities of head,
heart, and hand” that are necessary for the successful practice of the
art of peripheral anesthesia, it will have served a useful purpose and
discharged a worthy mission. In this hope I wish it Godspeed.
RUDOLPH MATAS.
PREF ACE
IN presenting this volume to the profession I have hoped to fill
what I have learned by my experience as a teacher is a real want in
the surgical literature of the English language.
Many small monographs have been available for the general
surgeon, and some excellent books dealing exclusively with the Spe-
cialties have been published, but no book in our language has at-
tempted to survey the entire field, giving the essential elements in
the successful application of local anesthesia to major Surgery, as
well as a systematic and detailed description of the methods of anes-
thesia suitable to operations in the different regions of the body.
The excellent work of Professor Heinrich Braun is a masterpiece
and a model of German thoroughness and comprehensiveness, and
I have availed myself of this fountain source of information in both
text and illustrations through the courtesy of Professor Braun him-
self and of his obliging publisher, Herr J. A. Barth.
When this volume was first undertaken it was intended that it
should be a joint contribution from Professor Rudolph Matas and
myself, an accomplishment of which I would truly have been proud;
however, lack of time and the urgent press of other duties have forced
Professor Matas to withdraw his direct collaboration, leaving to me
this responsibility.
I feel it is fitting that a pupil and close associate of his should
assume this task. It was at his side that I received my first lesson
in local anesthesia, and derived from him that enthusiasm and zeal
for this work that has made this book possible. It was his hand
that opened the door to my surgical career, and from that hand I
have received a generous bounty since. His name will always be
numbered among the pioneers of local and regional anesthesia—with
Corning, Halsted, Crile, and Cushing in this country; Schleich, Braun,
Reclus, and Barker, abroad.
While deprived of his collaboration in the authorship of this
work, I have quoted liberally from his writings and drawn still more
liberally from his ideas and spoken teachings on this subject. To
- 9
IO PREFACE
him is due the credit of working out successfully the first route to
the Second division of the trigeminus and blocking it with Meckel’s
ganglion and its branches, through the sphenomaxillary fissure and,
in this way, painlessly resecting the upper maxilla, a method which
by German authors is still erroneously credited to Payr. The Germans
(Braun, Härtel, et al.), however, credit him with the inframalar
route for reaching the inferior maxillary division at the foramen ovale
to which they have attached his name. With the aid of this proced-
ure he had resected the lower jaw many times, long before Schlösser
had popularized this route for the alcoholization of this nerve in
trifacial neuralgia. He first worked out a satisfactory method of
regional anesthesia of the forearm by blocking the nerves at the
elbow, and, independently of Crile's earlier work, he had amputated
the leg and thigh several times by blocking the sciatic, anterior crural,
obturator, and saphenous nerves. He performed the first operation
under spinal analgesia in America, and devised several types of ap-
paratus for massive infiltration anesthesia. Such terms as “intra-
neural,” “perineural,” and “paraneural,” as applied to regional
neural methods, were first introduced by him, as acknowledged by
Braun, at a time when such niceties of classification were unknown
in the literature.
His earlier accomplishments in this field have been overshadowed
by his later and far-reaching contributions to other departments of
surgery, more particularly by the various operations for the radical
cure of aneurysm which are permanently linked with his name. In
this way, his work in anesthesia has been overlooked or forgotten
by many, who aware only of the marvelous efficiency of this branch
of Surgery at the present time, are oblivious of the laborious steps
that have led to its present evolution. I feel it a fitting task, there-
fore, that the recital of Professor Matas' early achievements as they
appear in the following pages should devolve upon me.
The fundamental work on “nerve-blocking,” which has so intimately
and inseparably associated the name of Crile with the early history
of regional anesthesia, is now supplemented by his epoch-making
studies in anoci-association and in their practical application. The
growing appreciation of these principles has made a thorough knowl-
edge of local, and especially regional, analgesia more than ever neces-
sary to the progressive surgeon who would follow the teachings of
this eminent leader.
A very extensive bibliography had been prepared upon which the
author had expended much time and laborious research; it was in-
PREFACE II
tended as an appendix to the volume, which would have been of service
to the student of the history and literature of the subject. It em-
braced a list of over six thousand references, covering several hundred
pages. Unfortunately, as the text grew in size, it was found that
even an abridged bibliography would have so far exceeded the pro-
posed dimensions of the volume that it would have been too ponder-
ous for the purpose for which it was originally intended. At the sugges-
tion of the publishers it was deemed best to abandon this publication, a
determination which has been a sore disappointment to the author,
who in this way had expected to make a full acknowledgment of
every publication referred to in the text; as it is, many important
references have been regretfully omitted.
The author now desires to express his special and grateful obliga-
tion to the many authors and investigators quoted, whose writings
have so largely and generously contributed to the making of this
book.
In the preparation of this volume I am under particular obliga-
tion to my friend, Professor M. Feingold, for valuable assistance
and advice in the chapter on the Eye as well as in the general text;
to Professor C. J. Lanfried for assistance in the chapter on the
Ear, Nose, and Throat; to Drs. E. C. Samuel and R. M. Blakely,
of Touro Infirmary, for their kind assistance in the illustrations; and
to Miss L. Ambrose for her assistance in the translations. I am also
much indebted to Professors Arthur E. Barker, of London; Fritz
Härtel, of Berlin; and Guido Fischer, of Marburg, for the privilege of
making many quotations and the use of valuable illustrations.
CARROLL W. ALLEN.
NEW ORLEANS, LA.,
September, 1914.
CONTENTS
CHAPTER I PAGE
HISTORY. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I7
CHAPTER II
NERVES AND THEIR SENSATIONS.–ESPECIALLY PAIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Distribution of Sensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Philosophy of Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
OSMOSIS AND DIFFUSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CHAPTER IV
THE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA—COLD AND WATER ANESTHESIA. 58
Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Cold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6o
Water Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
CHAPTER V
LOCAL ANESTHETICS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Physiologic Action of Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Cocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Eucain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Akoin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8I
Holocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8I
Tropacocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Stovain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Alypin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Novocain Hydrochlorid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Chloretone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Orthoform. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9I
Nirvanin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Anesthesin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Subcutin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Propäsin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Comparative Action of Anesthetic Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Anesthetic Properties of Quinin Salts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ioé
- Anesthetic Properties of Magnesium Salts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II9
CHAPTER VI -
TOXICOLOGY. . . . . . . . . . . . • - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I 2I
I4 CONTENTS
CHAPTER VIII PAGE
PRINCIPLES OF TECHNIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I47
General Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I47
Solutions and Their Methods of Use... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I49
Classification of the Methods of Local and Regional Anesthesia in which Cocain
and the Other Allied Analgesic Drugs are Utilized as the Active Agents. . 153
The Armamentarium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I64
Clinical Application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I68
Cold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I73
Regional Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I73
The Constrictor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... • * * * * * * * * * I79
Technic of Handling Wounds in General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I79
Hemostasis and Closure of Wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I8I
The History of the Hypodermic Syringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I82
CHAPTER IX
THE USE OF MORPHIN AND SCOPOLAMIN AND COMBINED METHODS OF ANESTHESIA., 183
Morphin and Scopolamin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I83
Combined Methods of Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
CHAPTER X
INDICATIONS, CONTRA-INDICATIONS, AND SHOCK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I9 I
Indications and Contra-indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I9I
Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I92
CHAPTER XI
ANOCI-ASSOCIATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I94
INTRA-ARTERIAL ANESTHESIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2OO
Intravenous Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2O6
CHAPTER XIII
GENERAL ANESTHESIA THROUGH THE INTRAVENOUS INJECTION OF LOCAL ANES-
THETICS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2IO
CHAPTER XIV
THE UPPER AND LOWER EXTREMITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2I 2
The Brachial Plexus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2I5
Nerves of the Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
The Fingers and Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23I
The Lower Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
The Hip and Thigh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25O
The Knee-joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
The Leg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
CHAPTER XV
THE NECK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26I
Operations on the Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
The Larynx and Trachea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
CONTENTS I5
CHAPTER XVI PAGE
THE THORAX AND BACK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
The Sternum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29O
The Back. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29I
THE ABDOMEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Possible Scope of Operations within the Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . . . 338
CHAPTER XVIII
HERNIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Inguinal Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Femoral Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Umbilical Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Postoperative Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
CHAPTER XIX
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS. . . . . . . . . . . . . . . . . . . 364
Genito-urinary Organs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Penis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Scrotum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Chancroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! . . . . . . . . . . . . . . . . . . 377
Bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
Prostatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tº g & s 3 & 8 & 8 º' & # 8 & 9 & © 8 381
Anorectal Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |, . . . . . . . . . . . . . . . . . . 384
Gynecologic Operations. . . . . . . . . . . . . . . . . . . . . . . . * * * * * * * * * * * * * * * * * * * * * * * * * * * 393
CHAPTER XX
SPINAL ANALGESIA AND EPIDURAL INJECTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4O4.
Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4O6
Physical and Physiologic Factors Influencing the Movements of the Cerebro-
spinal Fluid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4O7
Anesthetic Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Isotonic Qualities and Specific Gravity of Anesthetic Solutions and Their
Movements within the Canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4IO
Indications and Contra-indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Technic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Failures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
In Obstetrics and Gynecology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Military Hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Phenomena of Analgesia: Course and Duration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Dangerous Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
After-effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Experimental Work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44I
Complications and Sequelae. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Urinary Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Effects of the Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Ocular Palsies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
The Method of Jonnesco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45o
Treatment of After-effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45I
Epidural Injections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
I6 CONTENTS
CHAPTER XXI
PAGE
PARAVERTEBRAL AND PARASACRAL ANESTHESIA. . . . . . . . . . . . . . . . • * * * * * * s is e s e < * g º e 454
Paravertebral Anesthesia. . . . . . . . . . . " * * * * * * * * * * * * * * * * * * * * * s a • * * * * * * * = e e s , s , 454
Parasacral Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... • * * * * * * * * * * - - - - - - - - - - 462
CHAPTER XXII
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
The Face. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Internal Maxillary Artery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Conduction Anesthesia and Injection Treatment of the Ganglion Gasseri. . . . . . 57I
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
CHAPTER XXIII
THE ORGANS OF SPECIAL SENSE, WITH DENTAL ANESTHESIA. . . . . . . . . . . . . . . . . . . . 579
The Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
The Ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Nose and Throat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Dental Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598
LOCAL ANESTHESIA
CHAPTER I
HISTORY
Divinum est opus sedare dolorem (divine is the work to subdue
pain). Thus spoke Hippocrates.
The history of the efforts of the human race to find a means to
control pain during operative procedure forms one of the most inter-
esting chapters in medicine. The writings of authors, from earliest
antiquity down through the long centuries, deal with efforts in the
behalf of human suffering. Sometimes surrounded by superstitions
at times the most ridiculous; later, as knowledge increased, based
upon more or less reason, but all futile and attaining the desired end
only to a limited degree.
- Among the earlier references to the use of narcotics is to be found
the following from Homer's “Odyssey,” when Helen gave to Ulysses
and his comrades the “Sorrow easing drug,” which probably consisted
of the juice of the poppy and Indian hemp:
“Presently she cast a drug into the wine, whereof they drank—
a drug to lull all pain and anger and bring forgetfulness of every
sorrow. Whoso should drink a draught thereof, when it is mingled
in the bowl, on that day he would let no tear fall down his cheek, not
though his mother and father died, not though men slew his brother
or dear son with the sword before his face and his own eyes beheld it.”
During the siege of Troy the Greek surgeons used anodyne and
astringent applications to ease the pain of their wounded, which
probably had some antiseptic effect of which they were not aware.
The following is found in the “Iliad,” when Petroclus, in admin-
istering to the sufferings of Euryphylus, removed a dagger from his
thigh:
- “Cut out the biting shaft; and from the wound
With tepid water cleansed the clotted blood;
Then, pounded in his hands, the root applied
Astringent, anodyne, which all his pain
Allay’d; the wound was dried, and stanched the blood.”
2 17
I8 LOCAL ANESTHESIA
It is probable that primitive men used pressure and cold to be-
numb the parts and thus lessen pain. In time they no doubt learned
that pressure over the region of the nerves and arteries had a more
pronounced effect, though they probably did not know why. The
ancient Assyrians employed pressure over the carotids and produced
a certain degree of anesthesia by cutting off the blood-supply to the
brain, and performed their operation of circumcision in this way.
The aboriginal natives of Some countries practice this method to-day.
That this practice must have been widespread is borne out by the fact
that the literal translation of the Greek and Russian names of the
carotid artery is “the artery of sleep.” -
The ancient Egyptians used the juice of the poppy and Indian
hemp before surgical operations. They also used a certain kind of
“Stone of Memphis,” which was supposed to have special virtues,
and was probably a carbonated rock. This they wet with sour wine
and applied it to the wound or the region to be operated upon, thus,
no doubt, generating carbonic acid gas. Accounts do not say whether
they were aware of this chemical reaction or knew the action of
carbonic acid gas. The Egyptians also used the fat of the “holy
animal of the land,” the crocodile, or its dried and powdered skin,
to produce local anesthesia. What results were obtained by these
methods is not known, but they were nearly always combined with
the internal administration of alcoholics and such narcotics as they
knew of.
Gold and silver instruments were supposed to cause less pain than
others; also warmed and greased instruments. This practice was
made use of in later times. It is stated that Lord Nelson was so
painfully affected by the chill of the surgeon's knife when his right
arm was amputated at Teneriffe, that at the Battle of the Nile he
ordered his surgeons to keep hot water ready to warm their knives
before using them.
The ancient Greeks also knew of the sedative and anodyne proper-
ties of many plants, from which they made ointments and lotions.
Aphrodite is said to have thrown herself on a bed of lettuce and
mandragora to lessen her feelings of grief over the death of Adonis.
There is probably no medicinal plant with which was associated
more ridiculous and absurd superstition than Mandragora atropa.
Much of this superstition no doubt grew out of its fancied resemblance
to parts of the human body, and the more accurate this resemblance,
the more highly was it valued. The growth of this plant must have
been widely distributed throughout Europe, Asia, and Africa, for it
HISTORY I9
was used by all of the ancient races. The Babylonians used it two
thousand years before Christ. The ancient Egyptians, Hebrews,
Hindus, and Chinese all used it.
The Chinese early recognized the local anesthetic action of many
drugs. Certain subjective tribes were made to pay their tribute in
such plants. In the middle of the twelfth century a pupil of the
Salernitana School wrote a treatise on the local sedative action of
opium, mandragora, and hyoscyamus. Even up to comparatively
recent times many native Chinese surgeons, who knew of the dis-
covery of chloroform, continued to practice anesthesia by the older
methods. Fat, marrow, and lizard oil were also used by the Chinese,
who attributed to them certain sedative action.
Freezing by the use of ice or snow was sometimes resorted to to
produce local anesthesia, thus foreshadowing the use of ether and
ethyl chlorid for this purpose. Thomas Bartholinus, a pupil of the
Neapolitan anatomist, Marcus Aurelio, first introduced it in the
middle of the sixteenth century.
At times many methods were forgotten and again revived. In
the middle ages pressure, which seemed to have been forgotten, was
again brought into use. Constrictors were then first used to deaden
the sensibility of the parts by cutting off the circulation and to
prevent hemorrhage after amputation. Velpeau later recommended it.
In 1784 J. Moore, of England, devised a constricting apparatus
which, when left in place one and a half hours, combined with the use
of large doses of morphin, permitted painless peripheral operations.
Moore's apparatus produced a high grade of venous stasis, and,
through many failures, fell into disuse and was forgotten.
In the middle of the last century Esmarch introduced his con-
strictor and bloodless method of operating, which was soon adopted
in all countries, and is the same as is in use to-day.
Cold, like other anesthetic methods, was forgotten, but revived
again by J. Hunter, who carried out painless experiments on animals,
Larrey, Napoleon's chief surgeon, reported that at the battle of
Eylau in 1807, with a temperature of –19°F., amputations were
almost painless. Later, through the observations of Arnott in 1848,
Guerard and Richet, 1854, but especially through Richardson, 1866,
was the refrigerating of the tissues for surgical purposes put upon a
firm foundation by the use of ether sprays.
Percival in 1772 discovered the anesthetic properties of carbonic
acid gas when sprayed on a raw or denuded surface, but was found
to have little or no action on the intact epidermis.
2O LOCAL ANESTHESIA
The electric current was first used in the middle of the last century
to produce local anesthesia through cataphoresis with various drugs.
The discovery of the hypodermic syringe by F. Rynd, of Edin-
burgh in 1845, though erroneously attributed to Wood, marked the
beginning of a new era. Morphin Solutions and tincture of opium
were injected into the tissues and around nerve-trunks with the idea
of deadening them, but, while these agents possess some slight local
anesthetic action, any decided effect which was obtained was due to
their general action; however, many operations were performed under
their use, administered in this way, and are reported as having been
comparatively painless.
Other substances, such as chloroform, which also has slight local
anesthetic action, were similarly used, but the irritating results of
their injection soon caused them to be abandoned.
The introduction of general anesthesia about this time, instead
of lessening the interest in local anesthesia, seemed only to intensify
the efforts and increase the zeal of those engaged in the Search for a
safe and efficient local anesthetic; these labors were soon to be re-
warded.
The first cocain was obtained from the coca leaves, but later was
prepared synthetically. The first report of the anesthetic properties
of cocain was when Scherzir reported anesthesia of the tongue after
chewing the leaves.
Godeke, as early as 1855, had isolated a principal from the leaves
of the plant, which he called erythroxylin. A few years later Niemann,
in a further investigation of its action, noticed that it produced
numbness of the tongue, both when the leaves were chewed and when
the alkaloid was placed on the tongue. He first gave the name cocain
to the active principal.
In 1874 Bennet demonstrated that cocain possessed anesthetic
properties.
Von Anrep in 1879 made a thorough investigation of the drug,
and used it hypodermically upon himself, injecting a weak solution
under the skin of his arm, and found that it first produced a sense
of warmness, followed by anesthesia. The stick of the needle at this
point no longer gave pain. The anesthesia lasted about thirty-five
minutes. In his discussion he suggests the possibility of its being
used as a local anesthetic for surgical purposes.
Cocain had already been known as a mydriatic, but Coupard and
Borderon in 188o discovered its local anesthetic action when dropped
into the eye.
HISTORY 2I
Karl Koller undertook a series of experiments on animals in Prof.
Sticker's laboratory, and demonstrated the complete anesthesia of the
eye by the use of a 2 per cent. Solution. The anesthesia lasted, on an
average, ten minutes. This was followed in 1884 by his announce-
ment at the Ophthalmological Congress at Heidelberg.
The tremendous value of this discovery soon led to the universal
use of the drug in ophthalmic operations all over the civilized world.
Its use Soon spread to other fields, and was applied to the mucous
membrane of the nose, throat, and larynx, with gratifying success as
an anesthetic.
“Within the short period of twelve months the newly discovered
properties of the drug had been tested in every important clinic of the
world, and the utility of cocain as a surface anesthetic had been put
to trial in every form of intervention in which the insensibility of
exposed or accessible mucous or cutaneous surfaces could serve the
purpose of the Surgical specialist or therapeutist. Thus it happened
that, within an incredibly short space of time, a new literature sprang
into existence, in which was reflected the experiences of ophthalmol-
ogists, otologists, stomatologists, dermatologists, genito-urinary Sur-
geons, gynecologists, and obstetricians” (Matas).
Untaught by experience, and too early yet for experimentation to
have shown the toxicity of the potent yet dangerous drug, many cases
of poisoning and death naturally followed its use in concentrated
Solutions and in large quantities. t !
Owing to the importance of this drug, the first and representative
type, as well as the standard by which the action and therapeutic
value of all other similar agents are judged by comparison, and its
early record so replete with interesting facts, it seems that a few
remarks regarding the history which surrounds its earlier cultivation
and use may prove desirable.
The plant formerly played a large part in the religious rites of the
natives of Peru. It was considered as a heavenly gift, which “satisfied
the hungry, gave life to the tired and exhausted, and made the un-
fortunates #. their troubles” (Novinny). Those forced to heavy
labor or long, fatiguing journeys found exhilaration and stimulation
by chewing the leaves. During the time of the Incas its cultivation
was controlled by the royal family, who levied a tax on its production.
When Pizarro invaded the country in 1532 he found its use widely
distributed and much abused by excessive use. After conquering the
country the Spaniards first forbade its culture, but later monopolized
it and levied a heavy tax upon its cultivation.
22 LOCAL ANESTHESIA
The leaves in use by the natives are obtained from cultivated
plants, the wild leaves are unfit for use; its cultivation is generally
like that of coffee and tea shrubs. It is now more particularly culti-
vated in Bolivia, and large quantities are exported to Peru. Other
varieties of the plant grow in most South American countries—
Mexico, India, and Java.
The coca bush grows from 5 to 8 feet in height and is widely
branched, its flower is white or cream colored, and grows in little
fascicles, close against the bark on the older and leafless part of the
twigs. There is no particular season for gathering the leaves, which
are picked when they reach a certain degree of maturity. The first
crop can be gathered after about two and a half years from plants
grown from the seed, and continue to bear for about twenty to thirty
years. The leaves are picked by hand and dried in the Sun, and must
be kept absolutely free from wetting by rain or other moisture. Con-
siderable care is necessary for their proper curing, as much deteriora-
tion may result when improperly done, resulting in change of taste,
due probably to the formation of other products in the leaf.
In the countries in which the plant is indigenous the lower classes
still chew the leaves, but the better classes drink it when prepared as
a kind of cordial, liquor, or pousse café.
There are several varieties of the plant—the Huanuco or Bolivian
leaf, the Peruvian and Truxillo varieties—all varying slightly in some
particulars, as regards to size and shape of leaf, as well as to their
value therapeutically. In a general way the leaf is about I to 3 inches
in length, and from # to 1% inches in breadth, and of oval shape.
There is not much doubt that the species originated upon the eastern
slope of the Andes, probably in Peru, where it grows wild and has lost
some of its cultivated characteristics.
The following history of the plant is quoted from Rusby's article
in the Reference Handbook Medical Sciences, 1901:
“The coca plant was under cultivation at the time of the discov-
ery, and no clew to its introduction to cultivation could then be, or
has since been, obtained. It occupied an important place in the
religious and mythologic history of the people. This is of interest
here only because of the unquestionable fact that such esteem was
the result of an appreciation of its useful properties rather than, upon
the contrary, and as for centuries believed, the superstitious reason
for its being used.
“We may, therefore, dismiss its mythical history (see ‘Coca at
Home and Abroad,” Ther. Gaz., March and May, 1888; also p. 14,
HISTORY 23
1886) as being here unimportant, and consider its physiologic and
therapeutic history. Its expectorant, sialogogue, stomachic, car-
minative, emmenagogue, and aphrodisiac properties are among the
minor ones for which it was and is used by the natives. As a stomachic
it is recognized that its use before meals detracts from the appetite,
but its use thereafter relieves any discomfort resulting from excess,
while not appreciably inhibiting digestion. In fact, its general repute
is that of aiding digestion. The more important objects of its use is
as a limited cerebral stimulant, an anesthetic, a very peculiar muscular
stimulant, and an ordinary masticatory. As a cerebral stimulant it
filled the place of coffee. It was used before the latter was introduced,
and after that event it continued to be used by the natives, while the
much more expensive coffee was used by the foreign element. In this
direction its characteristics were to promote cheerful and hopeful
views and sentiments, without excitability, but rather with increased
calm. As an anesthetic its use was a general more than a local One,
though it was locally applied to ease pain, and its carminative and
stomachic uses were clearly of this nature.
“The object of overcoming the pains of hunger and of fatigue
were pre-eminent, while that of securing relief from pain by a mild
general anesthetic, in spite of increased wakefulness, was general.
“The term ‘muscular stimulant’ is not accurate, but is used for
want of a better. More lengthily stated, the plant was used to enable
man to perform more labor with less fatigue and with less nutrition.
Without regard to the facts of the case, this was the belief of its users.
In consequence of these effects, bodily or mental, they performed
almost incredible physical tasks, long-continued, upon a food Supply
the scantiness of which is equally astonishing, and with results not
injurious beyond causing temporary inconvenience.
“The special adverse conditions to be met with in these efforts
were the continued scaling of steep and high acclivities, with little
food and with a very scanty supply of oxygen, and under the necessity
of either attaining a high speed or transporting heavy loads.
“The above statements, in substance, were among the earliest
historic records promulgated concerning its use by the people of the
countries concerned, and they have been repeated, with assurance,
by all subsequent investigating travelers.
“Many of these travelers went to extraordinary lengths to test
their accuracy, and always with affirmative results.
“Travelers and foreign residents verified them by personal ex-
perience and very frequently relied upon them for personal help.
24 LOCAL ANESTHESIA
These assertions were met abroad by religious opposition because of
the heathen relations of the coca customs, by very great professional
conservatism, and, lastly, by discredit, because the leaves exported
for use largely failed, in the condition in which they were received, to
verify them. All the present importance of the drug in its own form,
or that of cocain, cannot be said to cover the same ground involved
by the native uses of coca leaves.
“There appears to be but one rational explanation of this broad
discrepancy, namely, change in properties which the leaves undergo
after being dried. This view has been verified by the writer by numer-
ous assays of the leaves soon after collection compared with others
made later.
“Preparations made upon the spot have also been found, by ex-
tended trial, to act more like the leaves as chewed by the natives than
like preparations made from the exported leaves.
“The details of the methods of use have been so often published
that any account of them appears Scarcely necessary in this article.
“The use of Llipta, or ashes with the bolus, is to be regarded
partly like that of condiments, especially of Salt as such, without
food. At the same time, the suggestion made by Holmes that the
effect of this alkali is to decompose the alkaloid, cocain, developing
new constituents which exert the desired physiologic action, is full of
food for thought experiment.”
The reader will find a continuation of the history of local and
regional anesthesia in the chapters on cocain and other anesthetics
that follow, beginning with Chapter IV.
CHAPTER II
NERVES AND THEIR SENSATIONS ESPECIALLY PAIN
IN the practical part of this discussion we are interested only in
the afferent nerves, and of these particularly those that transmit
painful impressions—the sensory nerves. However, the subject of
pain and nerve sensations generally is of such tremendous interest to
the physician as well as to the surgeon, as it is this one subjective
Symptom which brings us most of our patients, and which in its
protean and manifold manifestations we are daily striving to relieve.
No other phenomena connected with the life-history of the human
body has been so great a factor in the historic development of medi-
cine as pain. It can readily be conceived that the first medical thought
and first effort on the part of primitive man was directed to the
relief of pain. And yet, though it is the most universal symptom of
disease, it is the least understood, as there has been no adequate or
entirely satisfactory explanation of its nature and mode of action.
It would, therefore, not seem out of place, particularly in a discussion
of this kind, to deal more liberally with the subject and attempt to
advance some theory as to what is pain. We must admit that we know
less about the nervous system than about any of the other great sys-
tems of the human body, and the function of many parts of the brain
is as great a mystery to-day as it was to our medical forefathers. We
know absolutely nothing about the metabolism of the nervous system,
but certain anatomic and functional facts have been established upon
which various theories have been built, and it is from this information
that we will draw in the present discussion, considering first such
anatomic and physiologic points that should be borne in mind.
To many, most of these facts are an old familiar story, and their
repetition would scarcely be excusable, and may be regarded as a
superfluous waste of time, were it not necessary to consider them for a
proper conception of the theories to be later advanced.
The sensory nerves have their sensory organs at their peripheral
termination. These are of several kinds—touch corpuscles, end
bulbs, touch cells, and free nerve-endings—most of which are dis-
tributed to the peripheral tissues, cutaneous, mucous, etc. In addi-
25
26 , LOCAL ANESTHESIA
tion to the above, there are the Pacinian corpuscles, distributed in the
subcutaneous parts, usually lying in cellular tissue, at times deeply
situated between muscle bundles; their function is not clearly under-
stood, but they seem to be connected with the sensory apparatus,
probably with the pressure sense.
In addition to these, we have the nerves of special sense, which
are sensory nerves, only highly specialized in their function. Aside
from nerves of special sense, the various qualities ascribed to these
nerves are: (1) pain; (2) tactility, or common sensation; (3) locality;
(4) pressure sense, and (5) temperature sense. While in all operations
under local anesthesia we are concerned more especially at the time
with the pain-conducting function of the nerve, we must not lose
sight of the fact that most cutaneous nerves are trophic as well, and
the deeper nerves contain, in addition, motor fibers. The operator,
under local anesthesia, becomes especially a nerve anatomist, learning
to search out, inject, and protect each individual nerve, and does not
needlessly divide them, thus saving its sensory as well as its motor
and trophic function.
We have said that sensory nerves have their sensory organs at
their peripheral terminations, and we say that it is the brain that feels,
but the brain is absolutely devoid of painful sensations; the exposed
brain of a thoroughly conscious patient can be operated upon without
any sensations whatever of pain; stimulation of various parts of the
brain may give rise to other sensations, but never pain.
The nerves themselves have very little sensation, but refer any
stimulation or irritation applied to them to their peripheral distribu-
tion.
What is pain? Is it a special sense of these afferent nerves, or is it
an exaggeration of common sensation, a quantitative increase of sen-
sibility? If pain were a special sense and traveled along definite
nerve paths there ought, logically, to exist a pain center, for all special
senses possess a special center, and the same may be said of the other
cutaneous senses. All of our numerous experiments and many clin-
ical observations have failed to locate such centers.
The destruction in animals of the gyrus fornicatus, or the hippo-
campal region, is said to be followed by more or less loss of common or
tactile Sensation, and the entire destruction of these regions on one
side of the brain is followed by protracted hemianesthesia.
There is, however, no pathologic evidence to make the conclusions
drawn from these experiments applicable to man, and the anatomic
distribution of the sensory fibers, as their path turns outward from the
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 27
internal capsule, seems to prove that it is not. It is, indeed, a wonder-
ful thing that the most highly organized and complex structure within
the human body should be entirely devoid of painful impressions.
Although we are most familiar with the sensibility of the skin, and
believe that we perfectly understand the nature of the impressions
upon it, and the mode of conveyance to the sensorium, yet there is a
difficulty in comprehending the operation of all the organs of the
senses—a difficulty not removed by the apparent simplicity of that
of touch.
But, although the impression be thus traced to the extremity of
the nerve, still we comprehend nothing of the nature of that impres-
Sion or of the manner in which it is transmitted to the sensorium. To
the most minute examination the nerves in all their course, and when
they are expanded into the external organs of sense, seem the same
in substance and in structure. The disturbance of the extremity of
the nerve, the vibrations upon it, or the images painted upon its
surface, cannot be transmitted to the brain according to any physical
laws that we are acquainted with. Experiments prove what is sug-
gested by anatomy, that not only the organs are appropriated to par-
ticular classes of sensation, but that the nerves intermediate between
the brain and the outward organs are respectively capable of receiving
no other sensations but such as are adapted to their particular organ.
Any impression on the nerve of the eye, the ear, or on the nerve of
Smell or of taste, excite only ideas of vision, sound, or smell, etc. No
education or amount of exercise will enable one nerve to replace the
other. We cannot comprehend anything of the manner in which
nerves are affected; certainly we know nothing of the manner in which
sensation is propagated or the mind ultimately influenced.
The manner of determining the relative sensibility of different
nerves by comparison or a study of the many different causes affecting
sensibility is, at times, made extremely difficult, for the observer must
depend entirely upon the statements of the individual experimented
upon for his information; and in animals, as can be well understood,
the difficulties and possibilities of error are greater.
The senses are not equally developed in all individuals, and are
differently developed in man and animals, according to their different
needs. We find every organ of sense, with the exception of that of
touch, more highly developed in the brute than in man. In the eagle
and the hawk, in the gazelle and the feline tribe, the perfection of the
sense of sight is admirable; in the dog, wolf, hyena, and most animals
and birds of prey the sense of smell is uncommonly acute.
28 LOCAL ANESTHESIA
The term “anesthesia” denotes the loss of tactility and in its broad
acceptation of all other sensations as well; “analgesia” means the loss
of the sense of pain alone; “thermo-anesthesia,” the loss of tempera-
ture Sense.
Some individuals are affected peculiarly by what should be painful
Stimuli, and do not complain of pain as the most trying symptom;
thus, it is related that in the pre-anesthetic days a French surgeon
was amputating a limb, and, noticing an expression of great distress
upon the patient’s face, said, “I fear that I am causing you great
pain.” The reply was, “No; the pain is nothing, but the noise of
the saw sets my teeth on edge.”
We find it equally difficult to give a satisfactory definition for
pain. It may, however, be regarded as a peculiar discomfort or suffer-
ing caused by disturbances of the sensory nerves or nerve-cells, which
induce a condition of overstimulation; thus, any of our sensations
may become painful if the stimulus is sufficiently strong or prolonged.
This will be illustrated later.
From a restricted philosophic point of view pain may be con-
sidered as a reaction of the organism, in part or in whole, to harmful
influences. This latter is more in accord with the views of the biologists
who see in the contractions and expansions occurring in minute proto-
plasmic life an expression, in a primordial way, of the senses of pleasure
and pain, expanding in response to pleasurable, healthful influences,
and contracting in reaction to painful or harmful stimuli. These
reactions are considered the germ of the idea which, by many multi-
plications, complications, and added phenomena, have come to make
the many-sided, complex figure of the human pleasure-pain sense.
There may be many kinds of pain, and no less real than those
pains due to the injury of a sensory nerve. We may have pain in con-
Sciousness connected with the more complex processes, such as fear,
anxiety, anger, or the pain of Sorrow or a “broken heart,” and other
conditions.
If pain is to be regarded as a reaction, there must be at least two
factors involved in its production: first, the susceptibility of the in-
dividual; and, second, the character or intensity of the stimuli or
inducing agency.
Pain may be to many but an incident of little concern, they are
either anesthetic or stoical, feeling very little or able to control their
expressions of pain; others are hyperesthetic or exaggerational, either
being extremely susceptible or they possess little or no control over
their feelings. These differences are largely individual, although there
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 29
exists certain factors in the race, age, social, and educational status
of the individual which influence this susceptibility; thus, it is stated
that the dark skinned races, Slavs and Teutons, are less susceptible to
pain than other races, while the Latin and Semitic stock are most sus-
ceptible. Old age generally is less susceptible than youth or adoles-
cence, due to the more sluggish condition of the nervous system, while
infancy, due to the absence of the psychic influence and poor sense of
locality, may bear certain pain well, but is easily shocked by severe
trauma.
The Social condition, refinement, and educational status and oc-
cupation have much to do with the susceptibility to painful impres-
sions, as we would naturally suppose; thus, a highly refined individual,
following an intellectual pursuit, would be expected, from his mode of
life, breeding, and occupation, to have a more highly developed and
sensitive nervous system than the laborer or farm hand, accustomed
to exposure with the knocks and buffets of a hard life. The inability
to bear pain on the part of certain high-strung individuals of nervous
temperament must not be ascribed always to cowardice, for such
persons often bear themselves with great fortitude and heroism when
exposed to grave danger; this has often been noticed in military
officers who have always shown great bravery on the battlefield, but
who would complain bitterly when pain was inflicted during some
minor attention.
In this last class of cases the psychic state of the individual plays
a large part. Of this factor we shall have more to say later.
Any of our Sensations may become painful if the stimulus is suffi-
ciently strong or prolonged; the skin touched lightly affords normal
tactile sensations, but if the pressure is severe, a general impression
approaching that of pain is produced.
The same may be said of thermic sensations; while the power of the
skin to recognize differences in temperature is very acute, the ability
to judge the absolute degree of temperature is very slight. When the
degree of temperature is raised or lowered beyond a certain point
the thermic sense is no longer excited, but sensations of pain are
produced. If we put our hand into freezing or very hot water, it is
difficult to say at once whether it is hot or cold, in either case pain
being the only sensation produced. The time for the arrival of tem-
perature impressions at the brain is remarkably long when compared
with the rate at which tactile impressions travel. That there must
be special nerve-endings for the reception of thermic impressions
would seem proved by the following facts: When heat or cold is ap-
3O LOCAL ANESTHESIA
plied to a nerve-trunk it does not give rise to these sensations; if a hot
or cold object is moved slowly over the surface of the skin Some parts
feel no temerature change, some feel increased heat, and others only
cold. These “hot” and “cold” perception areas are said to possess
different kinds of nerve terminals. It would seem that these nerve-
endings are different from those which receive tactile and pressure
impressions, because the appreciation of differences of temperature is
very delicately developed in certain areas where tactile sensation is
not most acute. Thus, the cheeks and the eyelids are very sensitive
to heat, while sensation is not most acute here; the middle of the chest
is also very sensitive to heat, but very dull to tactile impressions.
That all the different sensations of the skin possess different
nerve-endings or paths for their transmissions is again argued in
the difference between the senses of locality and pressure, as the
pressure sense is found to be not so keenly developed in parts where
the sense of locality is most acute. This sense of pressure may be
more accurately determined by the skin of the forearm than by that
of the finger-tip, although the latter is nine times more sensitive to
ordinary tactile impressions.
Any of these sensations, with the exception of that of locality, may
become painful if increased beyond a certain point. The same may
be said, in a modified way, of the exercise of the functions of special
sense. Moderate light does not prove of discomfort to the normal eye,
but if intense the pain may be severe. It, however, has been observed
that in cases of total blindness due to atrophy of the optic nerve very
intense light may produce pain. It is probably then not the optic
nerve, or not it alone, which feels the pain of overstimulation, but the
trigeminus. Sounds, such as music, cause pleasure when conveyed to
the brain over the auditory nerve, but if it were possible that these
pleasurable Sounds could be magnified to a high degree they would
undoubtedly become painful, but here, as in the case of the other
noises which set up violent Sound-waves, it is probable not the audi-
tory nerve, or not it alone, as in the case of the eye, which feels the
pain, as it is most likely due to mechanical injury to the tympanum
and OSsicles Supplied by the fifth nerve. Certain tastes or odors,
when of moderate intensity, are pleasant, but may become decidedly
disagreeable, or provoke other unpleasant sensations when markedly
increased. But here these special end-organs seem to have a chemical
function, while the excitation of nerves generally is rather of a mechan-
ical nature.
It will probably now not be out of place to consider certain other
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 3I
facts in connection with pain and sensations generally. Pain may be
caused by mechanical, thermal, chemical, electric, or other means.
The duration and extent of a stimulation may determine in great
measure the Sensations produced, as illustrated by the contact of a
hot surface for a short or long time, or by picking the skin lightly with
one pin or with a number at the same time.
There are some facts which seem to point to the conclusion that
pain has a functional independence, whatever may be said regarding
its anatomic independence; that is, whether there are special nerve
fibers which conduct pain, a point on which laboratory experiments
are conflicting or in doubt. As an illustration, pain may be abolished
without destroying or impairing any of the other sensibilities as is seen
in analgesia, brought on by the administration of a general anes-
thetic, in which observations prove the fact that pain disappears first,
then memory.
On the other hand, other sensations may be destroyed while pain
remains. When a part of the body (an extremity) is rendered anemic,
tactility disappears first, followed by pain, then the thermic sense.
Pain rarely ever remains constant in the same degree, but inter-
mits, while the stimulus may remain constant. This intermittance
may take the nature of a throb as in headache, jumps as in tooth-
ache, or as in bone-felons, in which the paroxysms become overpower-
ing. These intermissions in some cases are no doubt synchronous with
the pulse, or due to other reactions in the vascular system, bringing
about distension or vascular contractions, Other influences also
determine the onset of the paroxysms or increases of intensity as seen
in neuralgias.
Certain other phenomena are a delay noticed in recording a pain-
ful impression following a blow. The shock from the blow is often felt
an appreciable interval of time before the pain is felt; this may or may
not be due to the shock having paralyzed, for a moment, the Sensory
nerve-endings or their power of transmission. But this would hardly
seem the case in injuries of moderate severity which yet cause pain.
While we know that tactile impressions travel at the rate of 42
meters per second, and painful impressions only at the rate of Io meters
per second, still the delay is much greater than would be accounted for
by this difference.
Again, the lasting quality of a painful impression is sometimes
remarkable. Pains do not always pass away when the stimulation
ceases, but may remain for some time as an after-image. This is
probably due to the fact that the intense stimulation necessary for the
32 LOCAL ANESTHESIA
production of pain produce a more decided and lasting character in
the nervous changes than other sensations do. The demonstrated
fact that there exists definite pain-points, cold-points, heat-points,
and pressure-points in the skin would argue for the distinction and
independence of each of these Sensations.
The sensory apparatus, once excited, does not immediately sub-
side into a non-active state, but the pulse or wave of molecular change
which has been set up in the nerve centers remains for a longer or
shorter time. To better understand this phenomenon, we can take
for an illustration the optical delusion produced by a very rapidly
revolving torch which appears as a circle of fire, because the impression
created by the torch at any one point of the circle does not disappear
before it has again reached the same point; or the same may be illus-
trated in the revolving spokes of a wheel.
A contrast noticed in the apparent absence of pain when the
intensity of a painful stimulus is suddenly lessened, even though the
lessened intensity would be painful under other conditions, is ex-
plained in the above way.
Practically, all physiologists agree that we cannot feel two entirely
different sensations at the same time. One must be paramount and
the other subordinate, or each impression will be diminished, so that
their united influence would only equal what either would be alone.
And the same is true of painful sensations: a man with both legs
broken feels pain in but one at a time. The same thing takes place
continually with reference to all of our sensations, whether of pleasure
or pain; we are only conscious of what may be the paramount influence.
This fact explains in a great measure the psychic control over pain.
With the mind and attention occupied by some all-absorbing and
engrossing subject, great enough to hold the attention, pain is not
felt, as illustrated elsewhere in this discussion.
Another important consideration in the exercise of our sensations
is the necessity for a change of stimuli. Any sensation, whether
pleasurable or otherwise, if too long continued becomes weakened or
exhausted. It is only by constant change, contrast, and comparison
that we continue to exercise our many senses, but no two of them at
the same time. We can illustrate this by pleasurable sensations, we
will say at the theater, where the senses of sight and hearing are both
exercised, but alternately, the change enhancing and increasing the
pleasure derived from the exercise of the other. Music to the blind
is not so pleasing as to the more fortunate who can see, and the deaf
derive less pleasure from the sense of sight alone, although in either
NERVES AND THEIR SENSATIONS.–ESPECIALLY PAIN 33
case it may be the only amusement or distraction which they have.
Cold and heat are distinct sensations, and this is so far important
that without such contrast we should not continue to enjoy the sense,
for the variety of contrast is absolutely necessary to sensation. The
hand placed in moderately hot water soon becomes accustomed to it,
and we no longer feel the Sensation, or less so, and the same with cold.
The first shock is the greatest, and the hand alternately plunged from
moderately hot into cold water feels the contrast more keenly as the
Sense is excited by the change. It is by a comparison of cold and heat
that we enjoy either Sensation. All senses are exhausted by exercise
without change, but some are more lasting than others. We note
the relish with which one enjoys cool air after a long and exhausting
high temperature, or the comfort experienced by a warm fire during
the midst of a cold winter.
If we take, for example, vision, and gaze fixedly at a single color
or a single object, the sense is soon exhausted until we see nothing.
The psychic control over pain is very great indeed, probably much
greater than even the medical mind fully appreciates on casual thought.
This psychic control over pain, as well as over the other senses, is
thoroughly in accord with the recognized physiologic law that we can-
not be conscious of two sensations at the same time. With the mind
intently fixed on the idea that pain is to be inflicted the suffering is
always more acute, and vice versá, with the mind intently fixed and
absorbed by some object or aim in view the greatest mutilations are
possible without complaint. This is seen in the case of religious de-
votees and fanatics, who often inflict the severest personal chastise-
ment without apparent pain.
With the attention fixed on the idea that pain is to be inflicted,
and all the senses keenly alive and active, awaiting the impression,
the least touch or manipulation may excite the idea of pain and cause
the patient to cry out. One feels the stick of a pin much more keenly
when watching and waiting for it to pierce the flesh. On the other
hand, the most severe injuries may often be inflicted when the atten-
tion is diverted or the mind intensely fixed upon other things, as can
be illustrated by frequent incidents upon the battlefield, where arms
have been shot away or other severe injuries inflicted without the
individual being conscious of it until his attention is drawn to it. For
instance, we are unconscious of noises when our mind and attention is
firmly fixed upon other things, and with our mind so occupied we may
even look at things without seeing them.
Numerous illustrations could be given of the psychic control over
3
34 LOCAL ANESTHESIA
pain or its influence in producing shock. It is related that a French
criminal was experimented upon, being led to believe that he was to be
bled to death. He was accordingly blindfolded and prepared. His
arm was severely pinched, when he was told that a vein had been
opened. The surgeons who were making the experiment allowed a
small stream of warm water to trickle over the arm, pretending that it
was the escaping blood. One observer then took charge of the pulse,
and, pretending to count it, reported from time to time that it was
gradually growing weaker and the patient's strength failing. The
psychic impression was too much for the man to resist. He accord-
ingly grew weaker and weaker, being influenced by the suggestions
of those about him, who very seriously announced every few minutes
that he was gradually sinking. This was carried to the point of pro-
ducing psychic inhibition of the heart, resulting in arrest of its action
and death. Numerous other instances could be related, but one more
will suffice to illustrate this extreme psychic influence sometimes
exercised. A French soldier (Boutibonne) was in the thick of the fight
at Wagram. Men were falling all around him, when he felt both his
legs carried away by a cannon-ball. He sank down about 18 inches,
and fell back benumbed by the shock. He was told by those around
him that if he remained perfectly quiet it would lessen the hemorrhage;
he accordingly lay absolutely quiet until the next morning, when the
surgeons reached him and found that the cannon-ball had passed
through the ground beneath his feet, which sank into the furrow,
but that he had been entirely unhurt. (Related in “Sensation and
Pain,” Taylor, p. 55.)
The state of the mind has much to do with the activity of all
our senses. By our own mental operations we can deceive ourselves
by delusions of vivid reality, which at times can be controlled only by
our reason. By a mental state of dread, fear, or hope continuously
exercised we can excite in our senses sounds, visions, and other sensa-
tions. Shipwrecked sailors anxiously waiting and hoping for rescue,
with their eyes strained across a waste of water, eagerly seeking a sail,
often in their imagination see ships approaching, and these delusions
occur long before the bodily forces are exhausted by hunger and thirst.
Numerous similar accounts have been published by hunters and travel-
ers lost upon the prairies or desert, and, knowing that searching parties
would be sent out, have heard and seen in their anxiety the approach
of galloping horsemen in vivid reality, only to have the sight and
sounds fade away like a mirage on the exercise of reason. A similar
experience is related by Taylor in “Sensation and Pain.” In the early
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 35
days of Illinois he was lost on a dark night upon the prairie, There was
no danger, only the discomfort of remaining out all night. He wan-
dered for several hours trying to find his way, but to no avail. He
realized that his absence from home would make his friends anxious
and he would be searched for, he accordingly was on the alert for the
sound of horses’ feet and a voice calling. He listened intently, and
felt Sure of the approach of a galloping horse. The sound gradually
approached and grew more and more distinct, but finally faded away,
only to be repeated time and again. In reasoning over the matter he
concluded that his senses were deluding him; he then turned in the
opposite direction, and, after listening intently, he heard the same
Sounds from that direction and from any direction from which he
listened; he concluded that he was deceived by his own senses. He
then laid down to sleep and next morning found his way home, and
learned that no one had been searching for him. A scared child or
nervous woman will hear and see a thief in the room at night when
none is there.
Under similar conditions the senses of touch and pressure are equally
and vividly deceptive, and the same may be said of all our Senses.
Hypnotism is simply a more extreme concentration of the attention.
Very practical use can be made of the fact that sensations of
whatever kind are not only mental, but depend for force and quality
on the actual present state of the mind. Conscious sensation, whether
objective or subjective, is a mental act. A sensory impulse becomes a
conscious sensation only by producing a display of energy in the
cerebral nerve centers or brain of a certain or cognizable degree of
force, and then only when the attention is not engaged with other rela-
tively paramount sensations. “Attention, occupied with one sensation,
excludes other sensations while thus occupied” (Taylor).
Having recognized this psychic influence over our sensations, we
can readily understand why children and nervous individuals who
are unable to exercise any self-control suffer such mental torture when
about to undergo some trivial attention, and why such subjects, when
taken into an operating-room, with its strange surroundings, white-
capped and masked operators, to undergo some operation under local
anesthesia, with all their senses keenly alert in dreadful anticipation
of the impending procedure, magnify so greatly in their own minds
their sensations that tactility is often interpreted as pain, the least
touch causing them to jump and start with fright.
“Cowards die many times before their deaths;
The valiant never taste of death but once.”
36 LOCAI, ANESTHESIA
It is for this reason that the preliminary hypodermic of a small
dose of morphin, alone or combined with scopolamin, by dulling their
Sensibilities and mental activities, producing a somnolent, tranquil,
or inactive state of mind, thus protecting the patient against himself,
has proved so useful a preliminary or adjunct in all local anesthetic
procedures upon nervous or highly apprehensive individuals, thus
rendering valuable aid in the anoci-association of fear.
DISTRIBUTION OF SENSATION
The skin is the great sensory organ of the body, and to it are dis-
tributed most of the sensory nerves, but the distribution of these nerves
vary within certain limits. It is provided that the more a part is ex-
posed, and in proportion to its delicacy of organization, the more ex-
quisitely contrived and highly developed is the apparatus for its pro-
tection, and the more peremptory is the demand for the activity
of that mechanism, as in the case of the eye protected by its lids,
which acts involuntarily for protection and before the will could set
them in motion; and the same with the hand, which is involuntarily
withdrawn from the first touch of danger before the will can act.
The more exposed a part, the more highly developed is its sensibility.
The sensibility of the back and buttocks is dull when compared to
that of the face or hands. Tickling the lip with a straw or feather
becomes extremely unpleasant, while on the back it may not be felt.
Certain senses are limited almost exclusively to the skin, as tac-
tility, locality, and thermic sense; although with the latter certain
mucous surfaces feel both heat and cold, as experienced in the case of
hot or cold drinks too rapidly swallowed, when the stomach dis-
tinctly feels the sensation, or in the case of ice-water enemas, given
in cases of fever, the bowel feels the sense of cold.
Subcutaneous cellular tissue and fat have very little sensation.
In the subcutaneous fat-tissue and other parts further removed
from the surface are encountered the pacinian corpuscles, which
are visible to the naked eye as little globular-like masses. They
are connected with sensory nerves and transmit painful impres-
sions; what other function they possess, if any, is not known.
Between the muscle bundles are numerous small nerves which
are quite sensitive to pain, otherwise muscle-fiber is almost devoid
of sensation.
The periosteum is quite sensitive, acutely so in the inflamed
state. Bones receive nerve-fibers from the overlying periosteum,
but when the periosteum has been anesthetized or has been de-
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 37
nuded, the bone is then quite insensitive. Marrow is sensitive, but
varies greatly in different individuals. It receives nerve-fibers from
the same source as the bone, and when these have been anesthet-
ized or destroyed the marrow is then insensitive. The same can
be said of perichondrium and cartilage—the perichondrium is sen-
sitive, but cartilage not so.
Tendon-sheaths are Sensitive, but tendons and aponeurosis pos-
sess very little, if any, Sensation. Synovial membranes are quite
Sensitive. The mucous membrane of all the passages communicat-
ing with the surface are quite sensitive, that covering the gums and
hard palate much less So than that of the surrounding parts.
Some distance from the external openings these parts lose their
sensation. The mucous membrane of the esophagus and trachea
are insensitive; the esophagus, however, has a limited sensibility
for heat.
Vessels (arteries and veins), except of the smallest size, are sensi-
tive to pain, and this even in parts ordinarily devoid of sensation.
Fat has no sensations, but the vessels which course through fatty
tissue are quite sensitive.
In the omentum, which has no painful sensations, the large ves-
sels are quite sensitive and should not be clamped, ligated; or cut
without first blocking them. The vessels of the mesentery are also
quite sensitive.
These latter facts, and the sensitiveness of the various cavities
and their contents—cranial, thoracic, and abdominal—will be dealt
with in dealing with these parts.
All organs have certain sensations and respond to certain im-
pulses, nervous and otherwise, although normally we are not con-
scious of their actions. Thus, the heart, while insensible to touch,
is yet alive to every variation in the circulation, subject to change
from every alteration of posture or exertion, and is in Sympathy
of the strictest kind with the constitutional processes.
One of the most interesting theories of pain, and to us the most
plausible, at least in the present state of knowledge, is the theory
of quantitative increase of normal sensation. This beautiful theory
was admirably presented by that great philosopher of medicine,
Prof. C. Schleich, in his own inimitable, yet simple and effective
style, in an address on anesthetics at the von Bergmann Memorial.
The following quotations are extracts from this address:
“Is pain a sensation of physical discomfort conducted over ner-
vous paths designed for this specific impression, or is this general
38 LOCAL ANESTHESIA
Sensation of a threatening character only an increase or abnormal
excitation of the tactile sensation?
“Are these special nerves of pain implanted in the living organ-
isms to receive disturbing impressions, or do all sensory nerves,
that is, all ramifications of the cerebrospinal plexus, if abnormally
stimulated, become conductors of exceptionally perceptible cerebral
impressions? (2) Is pain only a quantitative increase of sensibility
or is it a psychonervous function of a special kind?
“If we accept Darwin's theory of evolution, all living tissue
must have been evolved by adaptation to the conditions of organic
life. Thus certain nervous paths, originally only Serving the sim-
plest tactile and reflex functions, might have evolved themselves
by adaptation and heredity into carriers of impressions of discom-
fort.
“This theory seems to me to be amply borne out by the observa-
tions, first reported by me and afterward confirmed by Lennander,
Block, and Braun, that all nervous paths appertaining to the vis-
ceral system, including the sympathetic system, that intermediary
brain, as it has been called, are primarily non-susceptible to pain-
ful impressions, only after the Surgeon has worked for some time
on the intestines, the walls of the stomach, or the uterus; the aston-
ished ganglia and nerve branches, never before bothered by external
interference, so to speak, recovering from their perplexity, become
sensible of the abnormal lesion and conduct and thus produce the
sensation of pain. Does not the accumulation of visceral pains
after some laparotomies, with their sudden attacks of postoperative
colic, speak plainly of the possibility of nervous pain, which, in the
economy of nature, originally were designed for entirely different
functions? Thus we see in operations, for instance, on the visceral
peritoneum, the evolution of nerves in a primarily insensible region
into conductors of pain, and the same process of evolution has taken
place on the external surface of the body. The tactile nerves have,
in the course of many thousands of years, learned to send, at the
irruption of external forces, a quick, incisive warning to the soul,
saying, ‘there is something threatening and destructive.’ Hence
pain is a warner, an exhorter, calling for defense, for fight, for the
employment of all measures of resistance and Self-preservation. But
how is it that in these central messages a contact, which is usually
transmitted as tactile, heat or muscular sensation assume at once
the character of a fiery streak, arousing the brain? How is it that
such a peculiarly eccentric stormy wave rushes over the special
NERVES AND THEIR SENSATIONS.–ESPECIALLY PAIN 39
paths usually transmitting only local impressions? This can only
be explained by the assumption that the impression of pain necessi-
tates a defect in the transmission, a disturbance in the current, and
the isolation. Here comes my theory of the inhibitory and isolating
function of the neurilemma and the neuroglia, which may be con-
densed in the Sentence that pain is the effect of an electric short
circuit of the Sensory nerve paths. All nerves are embedded in an
isolating sheath of connective tissue. The neurilemma plays the
same rôle as the green silk thread covering the copper wire of our
electric batteries. If the neurilemma is forcibly broken from the
outside, or pathologically loosened or softened from the inside, there
is a lateral short circuit comparable to a fiery spark into which all
the radiating nerve currents are discharged, and this short circuit
causes a general collective message of alarm to be registered in the
brain, notifying it of a defect at the periphery, differing greatly from
the usual impressions received over the same paths. This produces
a general impression of discomfort at being unable to quickly localize
the unusual general message, a sensation of confusion, with threats
of destruction, which chaotically rushes through the different centers
of perception, and it is this sensation which we conventionally call
pain.
“Its cause is an organic or dynamic lesion of the lateral inhibition
or isolation of the nerve branches. We must assume that the normal
tissue fluids have an inhibitory isolating influence, favorable to the
nerve currents, and that pathologic or artificial changes in the fluids
Surrounding and permeating the neurilemma may as readily cause
lateral short circuits, as foreign bodies, crystals, or micro-organisms
do which directly injure the isolations of the nerve branches. At this
point my deductive views had reached a promising stage. If this
theory of the function of connective tissue for the mutual isolation
was true, then there must exist ways and means to increase or de-
crease this isolation at will by the infiltration of fluids. That was
simpler than to investigate why, in some cases of edema of the skin,
the pain on introducing a needle is less than usual and in others
stronger. What was most obviously indicated was to determine
the saline contents of such edematous effusions, which proved that
the anesthesia of the swollen skin depended on an abnormally low
amount of salt present, while the hyperesthesia was caused by un-
usually high percentages of sodium chlorid, and this observation
was immediately confirmed by personal experiments. Welts in the
writer’s skin, produced with a .2 per cent. saline solution, were anes-
4O LOCAL ANESTHESIA
thetic, others from a 1 to 2 per cent. solution were painful, while
physiologic solution produced no disturbances of sensation.” * .
Equally interesting is the vibrating theory of nerve function,
which presumes for all nerve tissue a certain degree of rapidity of
vibration for functional activity, and is thoroughly compatible
with the theory of a quantitative increase of stimuli necessary for
the production of pain. This vibratory theory deals more with
the transmission of pain than with its cause. There is much to prove
this theory, both anatomically and physiologically. Many points
in the structure of nerve-cells is decidedly suggestive that these
cells, or their numerous processes, are in a state of active vibration
at least during functional activity.
We know that all matter in the universe is in constant motion;
nothing is ever at rest, organic or inorganic. Even the densest rocks
are constantly undergoing a molecular readjustment. This rule
applies also to all cells which go to make up animal life. Motion never
ceases in any kind of matter; in animals after death the kind of motion
may change, but no kind of matter is ever at rest. It is this un-
ceasing motion which contributes to bring about the constant changes
which are occurring in the world about us through the progress of
time.
Nerve function or nerve force is very closely allied to electricity,
with which all animal bodies are charged. Galvani first demon-
strated the electric current in the sciatic nerve of the frog. Since
then it has become an accepted fact that all animal tissue was cap-
able of producing electric currents, and that electric and nerve cur-
rents obey the same general laws (Helmholtz, Humbolt, DuBois-
Réymond).
Electricity is capable of exciting the function of nerves. Applied
to a motor nerve, muscular contraction takes place; applied to the
cheek, taste is excited; over the forehead, light is produced; and
when applied to the ears, Sound is heard.
Humphries, in quoting from Abrams, states: “Artificial electric
stimulation of nerve-fibers corresponds most nearly to their natural
excitation, and we, therefore, assume in our present state of knowl-
edge that nerve force and electricity are identical.”
If electricity is a form of motion, and moves along wires and
nerve currents, obey the same general laws which govern electric
currents, we are probably not far wrong in presuming that all nerve
function is a special kind of motion which takes place in nerve tissue.
We do not mean the constant molecular changes which are con-
NERVES AND THEIR SENSATIONS-ESPECIALLY PAIN 4I
stantly taking place in all tissue and have to do with repair and
growth, but a special vibratory motion, which takes place during
functional activity and is stilled or lessened during rest.
If this be accepted and nerves (their atoms or ions) be in a con-
stant state of vibration, an alteration or change in this vibration
affecting the conductivity or resistance may make itself known
to our consciousness by various sensations. We know that many
of these Sensations, which are known to our senses as sound, heat, or
light, are various degrees of motion. Sound means a vibration of
36,000 per Second; heat, 18,000,000 per second; while 462,000,000,000
vibrations per second produce light. Different colors are due to
different rates of vibration. Violet is the highest degree of vibra-
tion which we can appreciate, 733,000,ooo,ooo per Second.
Any disturbance which may bring about a readjustment of the
nerve elements, causing an altered conductivity or resistance, may
produce abnormal sensations; any stimuli, able to increase these vibra-
tions beyond the normal limit, producing pain, and when able to
lessen or alter them other sensations occur, a diminution or com-
plete stilling of the vibrations producing anesthesia; thus heat,
which is motion when increased beyond a certain point, causes pain;
and cold, which is the absence of motion, when lowered to a certain
degree by diminishing or stilling motion, produces anesthesia. This
vibratory theory explains why nervous or neurotic individuals, with
highly active and impressionable nervous systems, stand pain So
poorly, and why the phlegmatic, with sluggish and inactive nervous
systems, stand it comparatively well.
Some observers, accepting this vibrating theory, have claimed
that pressure, by bringing about an altered conductivity or resistance,
producing an alteration in the nerve-cells or in the nerve currents,
produced sensations of pain, and have claimed that all pain is pres-
sure; thus, headache, toothache, burns, inflammations, malaria, etc.,
by irritating the cells, causes them to swell, and this increased pres-
sure causes pain. Stasis is a form of pressure; this, however, is not
always felt at the point of pressure, but may be referred.
This theory, as pointed out by Humphries, is thoroughly com-
patible with the action of many agents used to control pain or produce
anesthesia; thus, general anesthetics paralyze the higher centers,
narcotics numb them or lessen their activity, and local anesthetics
paralyze the nerve-fibers or end-organs with which they come in
contact. Many agents act in a mechanical way; thus, external heat
or cold, a mustard poultice, massage, electricity, etc.—these may act
42 LOCAL ANESTHESIA
by drawing the blood to the surface or stimulating the circulation,
thus relieving the stasis or pressure at the effected point. This theory
has many advocates, and is one of the most rational advanced.
The difference noted in the rapidity with which painful and tactile
impressions travel, and spoken of elsewhere, is not at all incompat-
ible with the theory, for pain being an abnormal sensation greater
resistance may be offered to the transmission of the more violent and
abnormal vibrations.
In connection with the theory that motion of nerve tissue is
necessary for function, may it not be that in producing anesthesia
by infiltration, particularly when using sterile water, that the Swell-
ing of the cells induced by their taking up water (and in this case
giving off salts) may so interfere with their vibration as to prevent the
transmission of painful impressions.
This analgesic effect of the absorption of hypotonic solutions does
not necessarily contradict the above-mentioned views of some authors,
for, as shown elsewhere, as originally proved by Schleich, it is only
hypotonic solutions which possess this, power; isotonic Solutions
when injected have no effect upon sensation and hypertonic actually
cause pain.
PHILOSOPHY OF PAIN
Numerous writers and thinkers have devoted much time to the
philosophy of pain, and much that is worthy of the time and attention
of physicians has been written on this subject.
Plato and Aristotle have well said that neither pure pleasure nor
unqualified displeasure exist in man. Both feelings are mixed in
unequal proportions by the subtile art of Nature, and the definite im-
pression on our consciousness is a resultant in which one or the other
dominate. Pain is due to exhaustion, destruction, or rupture of sen-
sitive tissue; an increase of expenditure, with insufficient reparation,
produces fatigue and positive pain. All Suffering is partial death
which comes upon some organ or function.
“Pain is not to be reckoned as abnormal, but as Nature's protest
against the abnormal. It is her finger sternly pointing the other
way that she means us to go” (Crutcher).
The more consideration which we give to the subject, the more con-
vincing becomes the proofs that the painful sensibility of the skin
is a benevolent provision, making us conscious of those injuries
which, but for this quality of the nervous system, would bruise and
destroy the internal and vital parts which have little sensation. In
the first place, we must consider that if a sensibility similar to that
NERVES AND THEIR SENSATIONS.–ESPECIALLY PAIN 43
of the skin had been given to these internal parts, it would either
have remained unexercised or have made us painfully conscious of
our normal organic functions. Had they been made sensible to prick-
ing, burning, etc., they would have possessed a quality which would
never have been useful, since no such injuries could reach them,
or only after ample warning had been given through the sensitive
skin, and it would further inflict needless and unnecessary pain.
The deeper parts have different kinds of sensations, but a limited
degree of Sensibility, for they may be injured without injury to the
skin, as in fractures, etc.
“If we could imagine beings to have ever been created, by any
sport of nature, whose pleasure was connected with injurious ac-
tions and their pains with useful ones, they must have died out speed-
ily by virtue of the vice in their constitutions.”
“All suffering is a partial death which comes upon some organ
or function” (Fouillee).
To suppose that we could be moved by solicitations of pleasure,
and have no experience of pain, would be to place us where injuries
would meet us at every step and in every motion, and, whether felt
or not, would be destructive to life. To suppose that we were to
move and act without experiences of resistance and of pain is to Sup-
pose not only that man's nature be changed, but the whole of the
exterior nature also. There must be nothing to bruise the body or
hurt the eye, nothing noxious to be drawn in with the breath. In
short, it is to imagine altogether another state of existence. Pain
is the necessary contrast to pleasure; it ushers us into existence or
consciousness; it alone is capable of exciting the organs into activity.
It is the companion and guardian of human life.
In a broader conception of the statement we know of no instance
of pain being bestowed as a source of suffering or punishment, purely,
without finding it overbalanced by great and essential advantages,
and without being forced to admit that no happier contrivance could
be found for the protection of the body.
CHAPTER III
OSMOSIS AND DIFFUSION
IN considering the subject of osmosis, so that the reader may
reach a fair understanding of the action of fluids of different osmotic
pressure when injected into the body tissues, and place the sub-
ject before him in a brief concise way, is no longer easy. At one
time, following the discovery of osmosis by De Vries and his co-
workers, the problem was thought solved, and was supposed to be
limited to crystolloids or substances capable of Solution, while col-
loids either did not diffuse at all or only with great difficulty; since
then, as the result of the labors of many able investigators, the sub-
ject has been found to be not so simple; the perfection of delicate
instruments and improved methods of observations have shown that
the process, when applied to the movements of fluids within the
human body, may at times be extremely complicated and influenced
by many factors which escaped the observation of the earlier investi-
gators, and is to-day crowded with problems difficult of solution, the
discussion of which would take large volumes. It would probably
suffice, for all practical purposes in a work of this kind, to make a few
general statements which could be applied for all clinical purposes,
but, for a more thorough understanding of the subject, we are com-
pelled to go further and sum up a certain amount of experimental
and clinical evidence which bears more or less directly upon the sub-
ject, which, if it serves no other purpose, will at least show some of
the complicated problems which surround this process. In discuss-
ing this subject, if we will advance from the simple to the complex,
and consider the process as it takes place outside of the body, we
will ultimately arrive at a clearer understanding of some of the com-
plicated processes taking place within the body.
If two Solutions are brought together, containing different per-
centages of salts in solution, the process by which they mix is called
diffusion.
If they are put in different containers, separated by a permeable
animal membrane, they will also mix until the percentage of salts
in both containers is equal; this process, discovered by De Vries, is
44
OSMOSIS AND DIFFUSION 45
called osmosis, and the force which brings it about osmotic pressure.
The rapidity of this movement depends upon the permeability of the
membrane and the difference in the concentration of the two solu-
tions. During this process of interchange a continuous current
takes place in both directions, drawing salt from the stronger to the
weaker solution and water from the weaker to the stronger solution;
this process continues until the percentage of salt is equal in both
Solutions, osmotic equilibrium is then established, and the resultant
solutions are isotonic with each other.
If the content of one is increased over the other it is hypertonic
or hyperosmotic, and the one containing the lesser percentage of salt
is hypotonic or hyposmotic.
The above is the process in its simplest form outside the body, but
this process at once becomes more complicated when the solutions
contain different salts, where the molecular weight and diffusibility
vary, and is further influenced by the presence in one or the other
solution of a colloid to which the membrane is impermeable, but which
exercises its influence upon the interchange and the resulting tonicity
of the two fluids.
This is well put by Starling, in his book on “The Fluids of the
Body,” from which we quote the following:
“Thus, in the case of two solutions, A and B, separated by such a
membrane, if the osmotic pressure or molecular concentration of B
be higher than A, the force tending to move water from A to B will
be equal to this osmotic difference.
“There is, at the same time, set up a diffusion of the dissolved
substances from B to A and from A to B.
“The result of this diffusion must be that there is no longer a
sudden drop of osmotic pressure from B to A, and the result of the
primary osmotic difference on the movement of water will be minim-
ized in proportion to the freedom of diffusion which takes place
through the membrane. Now let us take a case in which A and B
represent equimolecular and isomotic solutions of A and B. It is
evident that the movement of water into A will vary as Ap-Bp=O.
“But diffusion also occurs of A into B and of B into A.
“Now the amount of substance diffusing from a solution is pro-
portional to the concentration, and, therefore, to its osmotic pres-
sure, as well as to its diffusion coefficient.
“Hence, the amount of A diffusing into B will vary as Ap, Ak.
when K is the diffusion coefficient. In the same way the amount of
B diffusing into A will vary as Bp, BK.
46 LOCAL ANESTHESIA
“Hence, if Ak is greater than BK–i.e., if A is more diffusible than
B—the initial result must be that a greater number of molecules of
A will pass into B than B into A.
“Hence, the solutions on the two sides of the membrane will be
no longer equimolecular, but to the total number of molecules of
A + B in B will be greater than the number of molecules of A + B
in A, and this difference will be most marked in the layers of fluid
nearest the membrane.
“The result, therefore, of the unequal diffusion of the two Sub-
stances is to upset the previous equality of Osmotic pressures. The
layer of fluid on the B side of the membrane will have an osmotic
pressure greater than the layer of fluid in immediate contact with the
A side of the membrane, and there will thus be a movement of water
from A to B.
“Hence, if we have two equimolecular and isomotic Solutions
of different substances, separated by a membrane permeable to the
dissolved substances, there will be an initial movement of fluid to-
ward the side of the less diffusible substance.
“Supposing the two vessels, A and B, to be separated by a mem-
brane which offers free passage to water and a difficult passage to
salts. Let A contain 5 per cent. Salt solution and B a solution iso-
tonic with a 1 per cent. NaCl, but containing only 65 per cent. of
this salt, the rest of its osmotic tension being due to other dissolved
substances. If the membrane were absolutely semipermeable, water
would pass from A to B until the two fluids were isotonic; i. e., until
A contained I per cent. NaCl (to simplify the argument we may
regard volume B as infinitely greater).
“If, however, the membrane permitted passage of salt the course
of events might be as follows: At first water would pass out of A,
and salt would diffuse in until the percentage of NaCl in A was
equal to that in B. There would not be an equal partial pressure of
NaCl on the two sides of the membrane, but the total osmotic pres-
sure of B would still be higher than A. Water would, therefore,
still continue to pass from A to B more rapidly than the other in-
gredients of B could pass into A.
“As soon, however, as more water passed only from A, the per-
centage of NaCl in A would rise above that in B. The extent to which
this occurs will depend on the permeability of the membrane. When
the NaCl in A reaches a certain concentration it will pass over to B,
and this will go on until equilibrium is established between A and B.
Extending this argument to the conditions obtaining in the living
OSMOSIS AND DIFFUSION 47
body, we may conclude that neither the raising of percentage of a salt
in a fluid above that of the same salt in the plasma, nor the passage
of a salt from a hypotonic fluid into the blood-plasma, can afford
in itself any proof of an active intervention of cells in the process.
“We have already seen that the effective osmotic pressure of a
Substance—i. e., its power of attracting water across a membrane—
varies inversely as its diffusibility, or as the permeability of the mem-
brane to it. What will be the effect, supposing that on one side of
the membrane we place some substance in solution to which the
membrane is impermeable? We will suppose that A and B contain
I per cent. NaCl, but that B contains in addition some substance ac,
to which the membrane is impermeable.
“Since the osmotic pressure of B is higher by the partial pres-
Sure of a than that of A, fluid will pass from A to B by osmosis.
But the consequence of this passage of water will be to concentrate
the NaCl in A, so that the partial pressure of this salt in A is greater
than in B. NaCl will, therefore, diffuse from A to B, with the result
that the former difference of total osmotic pressure will be re-es-
tablished. Hence, there will be a continual passage of both water
and salt from A to B until B has absorbed the whole of A.
“This result will be only delayed if the osmotic pressure of A
is at first higher than B, in consequence of a greater concentration of
NaCl in A. There may be at first a flow of fluid from B to A, but
as soon as the NaCl concentration on the two sides has become the
same by diffusion, the power of a to attract water from the other
side will make itself felt, and this attraction will be proportional to
the osmotic pressure of ac.”
Osmotic processes taking place in organic life, animal and vegetable,
become extremely complicated, and play an important part in regu-
lating the tissue fluids of both animal and vegetable life. The life
of the cell depends upon a continuous flow of the fluids which furnish
the nutrient materials, consisting, for the most part, of water, salts,
and albumen, which are present in certain proportions.
In plant life we do not have a complicated vascular system to
deal with, such as exists in animals, which adds further problems to
complicate the process; it was accordingly in plant life, with its
simpler physiology, that the problem was first understood and is
still being studied by those interested in this branch of investigation.
The human body is made up largely by protiens, fats, and carbo-
hydrates, all of complex molecular composition; the laws of osmosis,
when applied to such organisms, is highly complicated, and is not
48 LOCAL ANESTHESIA
yet thoroughly worked out; the colloidal proteins undoubtedly ap-
propriate the major part of this phenomenon, but the colloidal fats,
or lipoids and the carbohydrates, play their part in so far as they
have an affinity for water.
We can best obtain a conception of some of these processes by
considering the action of certain well-known colloids toward water
outside of the body. Fisher, in his book on edema, cites the action
of the two well-known animal colloids, gelatin and fibrin, toward
water; in the presence of water both swell to enormous proportions,
absorbing large quantities of water; we may add to these the action
of the vegetable colloid starch, which acts in a similar way. The
behavior of gelatin and fibrin is influenced largely by the reaction of
the solution in which they are placed, taking up water more rapidly
and in larger quantities when of slightly alkalin or acid reaction, but
more so with acids than when in plain water; however, the rates of in-
crease does not always correspond to the increase of alkalinity or acidity.
Many colloids may at times exist in crystalline condition, such as
egg-albumen and hemoglobin; there also exists many grades between
these two states when a substance may have a tendency in One or
the other direction. Fibrin, a typical colloid, is readily exuded into
the tissue spaces and as readily absorbed, apparently regardless of
the laws of osmosis. These colloids do not form true solutions, but
heterogeneous solutions, and show little or no tendency to osmosis,
yet many of them readily pass in and out of the tissues; such of the
colloids as gelatin and fibrin, which absorb large quantities of water, are
said to be hydrophilic.
These, and other facts to be mentioned, rather show that osmosis
is not the only factor at play in the movement of the body-fluids,
although it may play a large part, but still leaves many phenomena
which can now only be explained as the vital functions of cell life,
excretion or absorption as their function may be, and not that cells
are simply inert bodies which absorb or give off water to a surround-
ing medium regardless of other conditions, simply as this happens
to have an osmotic pressure higher or lower than that existing within
the cell, as certain chemical affinities may exist which exercise a
strong influence in one or the other direction. Thus Fischer, in writ-
ing on this subject in regard to the rôle played by acids and alkalis,
states the following:
“Two groups of substances have always stood out prominently as
exceptions to the laws of osmotic pressure, as considered active in
protoplasm, acids, and alkalis. The various tissue elements which
OSMOSIS AND DIFFUSION 49
have been examined in dilute solutions of these substances—red and
white blood-corpuscles, muscle, kidney, and liver-cells—all show an
absorption of water which is vastly greater than can be accounted
for on the basis of any idea of osmotic pressure. In fact, the amount
that muscle can swell in dilute acids has been employed by Overton
as a powerful argument against the ordinary osmotic conception of
absorption in general. He has shown very clearly that were all the
proteins, carbohydrates, and fats contained in muscle split up into
their simplest products, a sufficient yield of molecules and ions would
not be obtained to furnish an osmotic pressure adequate to account
for the water absorbed. We have no trouble in accounting for this
behavior of the acids and alkalis on the basis of our colloidal con-
ception. The acids and alkalis are the substance most capable of
altering the affinity of the hydrophilic colloids for water.
“The observations of Hamburger, that the volume of red blood-
corpuscles and the diameter of white blood-corpuscles increases pro-
gressively with every increase in the concentration of the acid or the
alkali in the solutions surrounding them, finds a ready explanation
in the facts outlined regarding the swelling of fibrin and gelatin.”
The action of animal tissue, particularly muscle, has been studied
in a similar way.
Loeb showed that muscle tissue does not change in weight if sus-
pended in watery solutions having the same osmotic pressure as the
blood, but that it gains or loses weight if placed in solutions of higher
or lower osmotic pressure.
This varies with the kind of salts forming the solutions, being
greater with potassium chlorid than if with NaCl and least of all with
calcium chlorid.
“A muscle swells more in the solution of any acid than it does in
pure water, but the amount of the swelling is greater in Some acids
than in others.”
“An important relationship exists between the concentration of
the acid employed and the amount that the muscle will Swell.”
“After a time a point is reached beyond which a further increase
is followed by a diminished absorption of water.”
“We have also no difficulty in accounting for the unequal Swelling
of cells in ostomotically equivalent solutions. We have found the same
to be true of the swelling of fibrin and gelatin. We have been able to go
even farther: we have found that the same group of substances which
have proved exceptions in the osmotic studies on cells also show a like
exceptional behavior when we deal with fibrin.”
4.
5O LOCAL ANESTHESIA
“To find an analogue for the failure of muscle, red blood-corpuscles,
and cells in general to shrink the calculated amount with every unit
increase in the concentration of the added salt is also simple. We
need only refer once more to the experiments on the swelling of
fibrin and of gelatin, in which we found that here, too, doubling the
concentration does not halve the volume; the amount of decrease is
always less than anticipated.”
“It is somewhat difficult to say what is the effect of alkalis on the
absorption of water by muscle. The statement is unquestionably
true that muscles swell more in the Solution of any alkali than water.”
This depended upon the condition of muscle (the acid content).
“When such muscles are placed in alkaline Solutions the alkali Com-
bine with the acid and the salt formed by the union inhibits the
swelling.”
Many conditions may influence the process. “It may at first
show a decided decrease, and later on equally decided increase, or the
reverse may be the case.”
“The addition of any salt to the solution of an acid decreases the
amount that a muscle will swell in that solution, and the higher the
concentration of the salt the greater is the amount of this inhibition,”
but different salts act unequally in this respect. Cases illustrating
the spread of anesthetic solutions by diffusion through the tissues,
where osmosis must play a small part, is seen in the wide distribution
of anesthesia following massive infiltrations, when the anesthesia
spreads quite a distance beyond the site of injection; also in hypo-
dermoclysis the fluid is seen to diffuse over a wide area; similarly in
Bier's vein-anesthesia, the solution filters through the vein wall under
pressure and diffuses through the entire thickness of the limb; such
extensive permeation would hardly be expected from osmosis alone.
We must also not lose sight of the fact that in the human body we are
dealing with a circulatory apparatus, and that the pressure in the
vessels is always greater than in the cellular interspaces, and that the
bulk of the absorption is done by the capillaries (lymphatics playing
but a small part). While it is not impossible for salts in a solution
under less pressure to find their way by osmosis into a solution under
greater pressure, it is nevertheless likely that in such vital phenomena
as absorption that osmosis must play a negligible or minor rôle, the
same as seen in the absorption of fluids from the intestinal tract.
Theoretically, according to the laws of osmosis, a hypertonic
solution should be absorbed more slowly than a hypotonic one, as the
fluid must first be rendered isomotic before absorption can take place.
OSMOSIS AND DIFFUSION 5.I
The hypertonic Solution must first abstract enough water from the
Surrounding tissues, while largely retaining its salts, until it becomes
isotonic when absorption can take place, while a hypotonic solution
begins at Once to give up its water. According to the above, on
theoretic grounds at least, the salts contained in a hypertonic solution
should be retained in situ longer, and in the case of anesthetic solu-
tions produce a longer anesthesia. In considering this question,
however, we must not lose sight of the fact that osmosis is a purely
chemicophysical process which takes place through a membrane, and
Cannot be unqualifiedly applied to living tissue, which exercises
certain physiologic functions and may absorb, regardless of the laws
of osmosis, in much the same way as fluids are absorbed from the
alimentary canal; but that osmosis does play a certain part we must
concede, and that we can favor this process by bringing about con-
ditions which will act favorably. Thus, it has been shown that
dilute acids and alkalis favor this process, more particularly acids;
alkalis, the weaker of the two in this respect, will not be considered,
and should be carefully avoided in all anesthetic solutions, as their
presence produces a decomposition of nearly all the anesthetic salts
used.
On the other hand, acids are favorable to the stability of the
anesthetic salts, which are acid derivations; the presence of small
quantities of NaCl and adrenalin solution used in most anesthetic
solutions, both of which have slight acid reactions, are sufficient for
our purpose, and enhance decidedly the absorption of the injected
solution by the tissues; as the presence of more than a minute trace
of acid is hemolytic in its action upon the blood-corpuscles further
additions are prevented.
Considering osmotic processes governing fluids injected into the
tissues, we must also bear in mind that these laws govern fluid under
equal tension, and when the tension of one or the other is increased
the fluid under greater tension is forced into the other by filtration.
Consequently, when we infiltrate the tissues with anesthetic solutions
under pressure regardless of its being hypotonic, isotonic, or hyper-
tonic, the injected solution, in consequence of this pressure, diffuses
in all directions, regardless of the laws of osmosis, and it is only when
lightly injected, in small quantities or in loose tissues, that osmosis
plays any decided part in the diffusion and absorption which takes
place; while hypertonic solutions may be absorbed with less rapidity
than isotonic or hypotonic ones, we are not concerned so much with
the value of the solutions from this standpoint as we are in selecting
52 LOCAL ANESTHESIA
Solutions which have no injurious action upon the tissues, for, since
the introduction of adrenalin, we are able to control to a great extent
the rapidity of absorption from the site of injection into the general
circulation by the use of this agent. -
The effect of adrenalin in influencing the osmosis and absorption
of fluids injected into the tissues must also be considered; where
the circulation is decidedly lessened or almost entirely arrested
(except in very vascular parts) by the use of this agent, osmosis has
a better opportunity to exercise its influence than in the presence
of an active circulation. Nose and throat specialists, who use concen-
trated solutions with a large content of adrenalin, are able to closely
observe its effect. Many such operators claim less constitutional effect
from the same amount of the anesthetic agent, in concentrated
form, than would be the case in using a larger quantity of a weaker
solution; most nose and throat specialists still prefer to use cocain,
which also exerts a vasoconstrictor effect. Solutions of high den-
sity are not readily absorbed by the blood-vessels, and by the time
they are sufficiently diluted to be absorbed the circulation has been
largely arrested by the adrenalin plus the vasoconstriction effect of
cocain, if that agent is used. When injected into practically ischemic
tissues, or tissues quickly rendered ischemic, the concentrated anes-
thetic osmoses into the surrounding cells and is largely fixed by them,
and is only washed out by the returning circulation, which is delayed
or held in check by Small quantities of the drug as it is being ab-
sorbed. In this way many of them explain the facility which they
use such strong Solutions.
The following well-recognized laws of physiology explain the
local retention in the parts of strong cocain-adrenalin solutions and
the prolonged anesthesia and ischemia following its use:
(1) A fluid passes through a membrane with a rapidity inversely
proportional to the destiny of the fluid.
(2) The rate of absorption varies directly with the fulness and
tension of the blood-vessels and lymphatics.
(3) The slower the movement of the blood and lymph-streams the
slower will be the rate of the absorption of the fluids.
In tissues rendered ischemic from the use of an Esmarch bandage,
or by gravity with a constrictor, injected solutions have a better
opportunity to enter the tissue-cells and exert the maximum effect,
though a limited amount of circulation may be favorable to a distribu-
tion of the injected solution, and the same effect can be obtained by
massage.
OSMOSIS AND DIFFUSION 53
As the object of this discussion is to develop a thorough under-
standing of the best way and means to produce an anesthesia of
Surgical intensity and of sufficient duration and extent to serve
every purpose, we have seen that osmosis can play but a limited
part; the body-fluids are in motion within the vessels, and the anes-
thetic is constantly being carried away. As will be shown the ac-
tion of any anesthetic is increased by a sojourn in the tissues, and
arrest or absolute stilling of the circulation, as obtained by the con-
striction of adrenalin, favors this effect. Our object, then, is to
develop an anesthetic solution which will possess as many of the
desirable qualities as possible, and at the same time prove non-
injurious to the tissues. A NaCl solution, containing o.97 per cent.,
is isosmotic for human blood-serum, a physiologic salt solution, and
has a freezing-point at .56°C., although red and white corpuscles
are affected different by changes in the strength of solution as well
as by the kind of salts used, yet these changes are, for the most part,
slight, and for all practical purposes where NaCl is the salt used,
as in the accepted anesthetic Solutions of to-day, the above should
Serve as a basis for calculation.
The simplest method of determining the osmotic tonicity of a
Solution as compared to another is to determine their freezing-points;
this, however, does not always decide whether or not a solution is
best for our purposes, for many Solutions may, as far as their os-
motic tension is concerned, be perfectly isotonic with blood-serum,
yet their contained salts exert a hemolytic influence upon the blood-
corpuscles, as will be shown in discussing the different agents used,
and as pointed out by Barker in the case of stovain, which is dis-
cussed in greater length in the chapter on Spinal Analgesia.
If a physiologic salt solution, O.97 per cent. NaCl, is slowly in-
jected at body temperature into the loose connective tissue of the
body in moderate quantity, neither swelling or shrinkage of the
cells is produced, and no after-irritation results, consequently no
pain is felt. If instead simple distilled water be injected, pain is
produced, due to an abstraction by the water of the salts contained
within the surrounding cells, while the cells absorb water causing
them to swell, thus macerating their contents, which may result in
the death of the cell; after the initial pain of the injection has sub-
sided a certain degree of anesthesia is obtained, the “anesthesia
dolorosa” of Liebreich. If concentrations of NaCl greater than
o.97 per cent. are used, the solution abstracts water from the cells
and causes them to shrink, giving rise to more or less pronounced
54 LOCAL ANESTHESIA
pain. These manifestations are proportionally the more intense
the greater the concentration of the solution, until tissue disturb-
ances may result which may terminate in gangrene.
The relative freezing-points of a large number of solutions com-
pared with blood-serum has been worked out by Prof. Braun. We
quote the following from his recent work, as well as copy the table
(Fig. 1) which he has prepared:
“On the horizontal line we find a list of the saline solutions from
o per cent. (plain water) to Io per cent.; of some of these solutions
the freezing-points are given. The black curve represents sensory
stimulation, which is felt as pain when the Solutions are injected into
the cuticle; the dotted curve shows the sensory paralysis (anesthesia)
Jrr//afton
------- Anesthesia.
*
*
* -
*
freezing poinſ. ..., doz' 25° 0'5/* dºg” d
A/a. cl. sod. ----21%----22% sº alſº oláž--- alé%_-_4.
25ugar Jol. ------ …! A f.....l.......'..…..
Cocain sol.-----90%------- &lº. &#------3% *
AEuca in Asok.-- *i. *. !.
25ch/elch so/-1 * * * ſ zºº." Aoinſ o. is: "
" *--------~~ l tº p , , o, /45 °
&g *g *~! & # .., 0, /3 *
Auman Blood.
Fig. I.-Diagrammatic representation illustrating the irritating and anesthetic action
of various hypo- and hypertonic Solutions on the tissues compared with human blood
(after Braun).
which follows this stimulus; the distance between the two curves
at any one point corresponds with the relative intensity of the stimu-
lus and the paralysis. The central point is occupied by the saline
solution of o.9 per cent. with a freezing-point of –55°C. This solu-
tion has, therefore, about the same osmotic tension as human blood;
all solutions on the left causing a swelling of the tissues, while those
on the right extract water from them.”
If the o.9 per cent. Saline solution is injected into the cuticle at body
temperature no pain is felt, no stimulation is induced, nor can any
change of sensibility be observed in the region of the welt, especially
no sensory diminution. The welt thus produced disappears very soon
without leaving any trace. If we now gradually decrease the strength
of the Solution, pain appears on injection, usually around o.55 per


OSMOSIS AND DIFFUSION 55
cent. On further dilution this pain quickly increases in intensity
and reaches its maximum when pure water is used.
“This latter injection is extremely painful; this pain which we
call welt pain is only of short duration, and is followed by a diminu-
tion and then, cessation of sensation in the injected area. The in-
tensity and duration of this phenomenon gradually increases and lasts
longest (about fifteen minutes) with pure water. We call it “welt
anesthesia.’ Very dilute solutions cause an injury to the tissues,
that shows itself in a painful infiltration at the site of injection. Pure
water causes, in a number of cases, superficial necrosis of the tis-
sues, ‘infiltration necrosis.’
“With solutions containing more than o.9 per cent. sodium chlorid
the symptoms caused by their affinity for water can be observed.
These symptoms also consist in stimulation, paralysis, and tissue
injury.
“But the stimulation manifests itself in a different way than in
the ‘welt pain'; it follows the injection, which in itself is painless and
lasts for several minutes, the site of the injection being strongly
hyperesthetic; this is followed by anesthesia. The welt at the same
time shows very peculiar and typical changes of form; when the
burning pain commences to diminish and the anesthesia begins the
center of the welt rapidly sinks down and forms a depression, while
the margin forms a circular raised wall. The anemic margin and
the anemic center are generally separated by a narrow red ring;
after about fifteen minutes the welt again grows uniformly flat and
its periphery becomes larger; finally, it disappears and sensation
returns. These concentrated saline solutions damage the tissues.
All these symptoms grow more intense with the increasing strength
of the solution. With 2.5 per cent. they are already noticeable,
and injection of saline solutions of more than Io per cent. can scarcely
be tolerated. A small degree of infiltration and taking up of water
cannot be observed; hence, there exists around the o.9 per cent. saline
Solution an indifferent zone, comprising a number of Solutions
(from o.55 to 2.5 per cent.), which do not cause the above-mentioned
Symptoms.
“But it must be remembered that the curves showing the pain
and sensory reduction do not represent absolute values. They were
the result of experiments on the skin of our own forearms. If saline
Solutions are injected in hyperesthetic tissues, or in very sensitive
persons, solutions of less strength will cause the above-mentioned
symptoms. The curves will here reach the horizontal line nearer its
56 LOCAL ANESTHESIA
center than in our experiments, and the apparently indifferent zone
will be narrower” (Braun).
But little work has been done on the osmotic pressure exercised
by the various local anesthetic agents and their hemolytic effect
upon the blood. As the hemolytic action of any agent is of prime
importance, the following conclusions, drawn by Bünte and Moral,
which deals particularly with novocain, the anesthetic salt now at-
tracting the most favorable attention, are deserving of considera-
tion:
“(1) The enveloping membrane of blood-corpuscles is perfectly
permeable for novocain, tropococain, etc.
“(2) Novocain solutions, etc., should never exercise an osmotic in-
fluence on blood-corpuscles.
“(3) Novocain solutions, to be isotonic for blood-corpuscles,
should be dissolved in a solution containing o.29 per cent. NaCl.
“(4) Novocain exercises a slight hemolytic action, which, in the
presence of a o.29 per cent. NaCl solution and when the novocain is
not too concentrated, disappears completely.
“(5) Solutions of novocain in o.625 per cent. NaCl Solution do not
cause hemolysis, but produce a swelling of the blood-corpuscles; after
prolonged standing the corpuscles show distinct signs of beginning
hemolysis.
“(6) If the content of a novocain-Saline solution is o.6 per cent.,
NaCl or less hemolysis does occur.
“(7) The values of lowering the freezing-point found in the
Beckmann apparatus on a novocain-Saline solution cannot without
any further work be applied to the calculations of the osmotic pres-
sure of blood-corpuscles.
“(8) No alkali, or even salts with alkaline reaction, can be added
to the novocain-Saline Solution, since a precipitation of the novocain
would occur.
“(9) The 2 per cent. novocain solution can, without diminishing
its action, be reduced to 1.5 per cent. with children and feeble indi-
viduals, even so far as o.5 per cent.
“(Io) Solutions containing non-indifferent substances are unfit
for injection; as such are to be considered alcohol-ether injections
(after Eckstein), since they coagulate the blood-corpuscles.
“(II) The 1.5 and o.5 per cent. novocain-saline-thymol Solution,
the end-result of our examinations, have come up to all expected
requirements, theoretic as well as practical.
“Its osmotic pressure is equal to that of the tissues, they have no
OSMOSIS AND DIFFUSION 57
hemolytic action on the blood-corpuscles and produce no injury to
the tissues.” -
After a consideration of the foregoing, the selection of a men-
struum for anesthetic agents becomes a matter of considerable im-
portance. The use of distilled water, as practised by some, while
under Some conditions producing fair surgical analgesia, is hardly to
be recommended for any extensive operative undertaking, as, on
physiologic grounds, it may be followed by sufficient injury to the
tissues to lead to necrosis. For similar reasons the o.2 per cent, solu-
tions of NaCl, as recommended by Schleich, has not been followed
by us, although producing good anesthesia, and, we must admit,
yielding good results clinically in the healing of wounds. In the
light of physiologic investigations the osmotic tension is too low;
it is probable that less injury would result and less after-pain occur
from the use of a solution containing slightly more NaCl. It is for
that reason that we have adopted solutions containing o.4 per cent.
NaCl, which, however, according to physiologic observations, is
still low enough to produce decided hemolysis, yet we have never
observed any unpleasant action from its use in several hundred cases,
but believe that there is a slight advantage in its favor, in that there was
less after-pain and Soreness complained of following its use, particularly
in large operations, than when using solutions of lower concentration.
Schleich claims for his solutions that the anesthesia is largely due
to their hypotonicity, upon which they largely depend for their
action, the content of anesthetic salts serving principally to lessen the
pain of infiltration. While their anesthetic influence is unquestion-
ably enhanced by their hypotonicity, their anesthetic content, though
weak, is still sufficient, when the tissues are thoroughly saturated, to
exert a decided anesthetic influence, as can be proved by using the
same strength of cocain and other salts dissolved in normal salt solu-
tion. While clinically we have no fault to find with Schleich's solu-
tions after an extended use covering many years, yet, in the light of
our present knowledge, on physiologic grounds we feel that a nearer
approach to an isotonic solution with human blood would have its
advantage and throw less traumatic burden upon the tissues in the
operative field; we have accordingly, for this reason, preferred to use
o.4 per cent. Salt Solutions.
Braun, in his solutions, uses o.8 per cent. sodium chlorid for
ordinary purposes of infiltration, but when stronger solutions are
used for special purposes he reduces the content of the NaCl pro-
portionately.
CHAPTER IV
THE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA—
COLD AND WATER ANESTHESIA
PRESSURE
PROLONGED pressure upon a nerve paralyzes its function, either
motor, sensory, or both. This is seen in many illustrations in daily
life, such as when the leg “goes to sleep” after crossing it, becoming
numb and difficult of motion for a few minutes. In sleeping with the
arms above the head, by pressure of the clavicle upon the brachial
plexus, one may awaken with a feeling as if the arms were dead, when
it may require some effort to lower them when the feeling soon passes
off.
This pressure, if persisted in for a sufficient length of time, and
particularly if combined with anemia of the part, may produce such
a degree of paralysis that the parts are practically analgesic, when
it is possible to perform peripheral operations with little or no pain.
However, pressure, persisted in to this extreme degree, becomes highly
dangerous, and may be followed by serious consequences as a result of
traumatic neuritis of the nerve-trunks, leading in extreme cases to
possible atrophic changes; this is seen usually in mild form in crutch
paralysis, or in paralysis of the upper extremity following anesthesia,
when, during complete muscular relaxation, the arms are held above
the head, causing the clavicle to compress the brachial plexus.
These consequences sometimes follow the injudicious use of the
Esmarch constrictor, but here it is more especially the circulation
which is interrupted, though occasionally damage may result from
pressure upon the nerves.
These procedures, resorted to in earlier days, were the best that
the surgeons then had at their command, as they knew nothing
about exsanguination; the constrictor was placed upon the limb
with its full content of blood within the parts, and was used more to
prevent hemorrhage than to obtund nerve sensibility, though some
made use of it for this purpose, but in either case the patient was
generally narcotized with alcoholics and drugs in use at the time.
It is highly probable that prehistoric man made use of these
58
THE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA 59
physical means, as well as the application of cold (ice or snow) to
lessen sensibility, as these practices are in use to-day among un-
civilized races, where it is handed down by tradition from one genera-
tion to another. The carotid arteries were called by some of the
ancients the arteries of sleep, as prolonged pressure upon them pro-
duced sleep, and this practice has been reported to have been in use
in fairly recent times.
It must, however, be borne in mind that, while the resulting
peripheral paralysis (motor and sensory) becomes more pronounced
the longer the pressure is continued, the discomfort at the point of
constriction is also progressively increasing the longer it is main-
tained, until it becomes decidedly painful, and may become un-
bearably so before any very decided impression is made upon the
peripheral sensibility.
The ability of the patient to stand an effective amount of pressure
will of course be determined to a large extent upon the care with which
the constrictor is applied; the same amount of pressure, if applied
to a narrow area by applying the successive rolls of the constrictor
one on top the other, becomes much more painful than when the
successive rolls, are applied progressively to a higher or lower level
of the limb, thus embracing a wider area. This care in having the
parts well padded before applying the constrictor has much to do
with the ability of the patient to comfortably stand the needed pres-
sure. While we now never use constriction or pressure for the pur-
poses discussed here, these facts must be borne in mind in applying
a constrictor to a limb for the purposes of ischemia when operating
under local anesthesia, when it is very unpleasant to stop during the
progress of an operation to loosen an uncomfortably tight constric-
tor. The stoutness of the patient is also a factor which must be con-
sidered in applying a constrictor; the required amount of pressure
must necessarily be much greater over a stout limb than over a thin
or emaciated one, and should be graduated accordingly.
The use of constriction for holding local anesthetic solutions
in situ will be spoken of elsewhere.
The well-known benumbing effect of long-continued pressure upon
any part of the body is well known; although some pain may be
produced in the surrounding parts, it is possible to carry it to a
point of depressing both tactile and painful impressions to a con-
siderable degree; this is brought about in two ways, first the compres-
sion directly paralyzes the nerve-endings of the part, and, secondly,
the anemia intensifies this effect.
6o LOCAL ANESTHESIA
COLD
It is highly probable that the first use of cold for its sedative
effect must have occurred in the remote past. Primitive man, with
his meager supply of aids and necessities, most likely made use of all
physical means at his command.
Military history contains many references to the sedative and
analgesic effect of cold. Larrey, Napoleon's chief surgeon, reports
that at the battle of Eylau, with a temperature of –19° F., that
peripheral wounds caused very little suffering, and that amputations
were practically painless when the limbs were first freely exposed to
the air.
The first record we have of its use in modern Surgery was by
Arnott in 1848, who employed bags or bladders filled with ice and
salt for their depressing or sedative effect upon the sensibility of the
part. -
The usual means by which cold is employed for its local anesthetic
effect in modern surgery is by the use of various gases or liquids of low
boiling-point, which are usually projected in the form of a spray upon
the skin, their rapid evaporation producing an intense cold which
freezes the parts. -
Sulphuric ether was the first agent used in this way. The first
atomizer or spraying apparatus was devised by Richardson in 1866,
and furnished the idea for all such instruments in use to-day. It
was found that a perfectly pure, water-free ether was necessary,
such as that used for anesthesia; it should have a specific gravity of
.720, and boil at 34.5° C.
It was later found that many other substances other than sulphuric
ether could be used for the same purpose, and the lower the boiling-
point the more intense was the cold generated by their evaporation.
These agents belong principally to the ethyl or methyl groups.
Ethyl chlorid (C.H,Cl), known under various trade names as kelene
or antidolorin, and also called hydrochloric ether, is used for both
general and local anesthesia; it is a colorless gas, liquified in tubes,
and has a boiling-point at 12.5 °C.; was first introduced by Rotten-
Stein, and has proved the most satisfactory and useful of all these
agents.
In the methyl group there are several local anesthetics; methyl
iodid (CHAI) is a colorless or brownish liquid, which exerts decided
local anesthetic powers, but is rarely used on account of its irritant
action. -
Methyl oxid is a gaseous or liquid substance which is strongly
+HE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA 6I
refrigerant. Methyl chlorid (CH,Cl), the most useful of this group
is a powerful agent; under high pressure it is a colorless fluid, with a
boiling-point of –23° C., and has to be kept in strong metal con-
tainers. The rapid evaporation of this liquid is said to produce a
temperature of –55° C., while ethyl chlorid produced —35° C.
Such powerful agents as methyl chlorid have to be used with great
caution, as the intense cold generated may injure the tissues and
cause necrosis; to avoid this danger it has been recommended to
Saturate tampons with the solution and place them upon the part to
be frozen; this lessens the intense cold produced by retarding evap-
oration; in this way freezing is said to occur in a few minutes, but
even with this precaution damage may result to the tissues.
To moderate the powerful effect of methyl chlorid various com-
binations with ethyl chlorid and other substances have been sug-
gested; thus methylil, which is a proprietary mixture, is a combina-
tion of methyl and ethyl chlorid with chloroform.
The rapidity and intensity of the local freezing action of any
of these agents, aside from their power to abstract heat, depends
upon the vascularity of the part, and the duration of its action is
influenced by the same factors; in highly vascular tissues this action
is less marked and of shorter duration than when the opposite condi-
tions exist, and in parts where the circulation can be controlled a
much more intense action is obtained, which is also of much longer
duration, and this action is further increased if the part is first ren-
dered ischemic, but when used under these conditions great care
is necessary to avoid permanent injury to the parts resulting from
coagulation of the blood in the superficial vessels terminating in local-
ized gangrene.
The local freezing action of all of these sprays first causes an ex-
treme degree of vasoconstriction, which is followed by a vasodilation
more or less marked, depending upon the intensity and duration
of the freezing process; this may persist as a red hyperemic spot at
the site of application for some time. According to Boeri and Sil-
vestro, the sense of pain is affected first and most intensely, tactility
next, while the pressure sense is affected least. The reaction of the
tissues from this freezing process is not always without pain, which
at times may be considerable and is of an aching, burning character.
When it is desired to obtain the most intense action of the cold,
in addition to the exsanguination of the part above suggested, it
is well to remove all fat from the skin by either ether or benzine;
but, on the other hand, it may be desirable to protect the parts,
62 LOCAL ANESTHESIA
particularly such tender tissues as the face, scrotum, etc., from a
too violent action of the agent, by first Smearing them lightly with
vaselin, or, as Prosoroff has suggested, by the interposition of thin
metal plates; something of this kind should be used particularly
about the eyelids. These agents are not suited for use about the
anus, and when used about the anal region these parts should be
first protected by tampons before applying the spray to the Sur-
rounding parts.
In using an ether spray care is necessary about an open fire or
near a cautery, but the same danger does not exist with ethyl chlorid,
which is not inflammable. However, none of these agents are quite
satisfactory when it is intended to use a cautery upon the parts,
although, if they are deeply frozen, a superficial cauterization may
be accomplished, but with such evanescent anesthesia as is obtained
with these agents the after-burning will be considerable; it is, there-
fore, better when cauterization is intended to use other means of
anesthesia.
These freezing sprays are best suited to superficial minor opera-
tions, which at most do not involve more than an incision, and may
have particular indications where it is not advisable to infiltrate an
inflamed or infected area with local anesthesia. Their especial claim
for usefulness is in the time that is saved. They will accordingly
be found most useful in opening boils or Superficially situated ab-
scesses, and the removal of foreign bodies, such as splinters, etc.,
from beneath the skin. When skillfully used as a continuous spray
they are also efficient in removing ingrowing toe-nails.
Certain venturesome operators have even attempted major
operations by their use alone; thus, Dolbeau has resected a scapula
practically without pain by a continuous spray, freezing as he ad-
vanced, but it is highly probable that such prolonged freezing would
be followed by serious after-consequences, and the same could prob-
ably have been done simpler and easier by other measures.
Spencer Wells attempted an ovariotomy and succeeded in getting
through the abdominal walls without pain, but had to abandon the
attempt and resort to general anesthesia to complete the operation.
Richardson and Greenhalgh were more successful with a Cesarian
section, which they completed with this means alone and almost with-
out pain. Such procedures as these are not of practical clinical value,
and are not to be recommended; they are principally of value in
showing what can be done under extreme conditions by skillful opera-
tors with these agents.
THE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA 63
To obtain the maximum effect from any of these sprays it is neces-
sary to hold the tube just far enough from the skin so that evapora-
tion is at its height by the time the spray strikes the skin; if held
too far away much effect is lost, and if too close the liquid will run
down on other parts or evaporation be delayed.
Regional anesthesia, by freezing the tissues over superficial situ-
ated nerves, such as the ulna at the condyle of the humerus, has been
tried, but there are hardly any indications or emergencies which
would arise to make this method preferred over the safer, surer, and
more surgical use of other measures.
Ethyl chlorid and other sprays are particularly useful in den-
tistry; for this purpose certain mechanical arrangements have been
devised with a two-pronged spray, so shaped as to spray both sides
of the gum at the same time. Kühnen was the first to invent and
use such an apparatus. Their particular claim for merit in den-
tistry is that in inflamed conditions of the gums less injury is done
by a freezing process than would be the case with infiltration, which,
under Such conditions, may be followed by Suppuration.
Many other means and agents have been used to obtain a local
anesthetic effect through the agency of cold. Dr. Mellish has called
attention to the fact that alcohol at –Io° F. produces complete
analgesia, but does not abolish tactility.
Carbon dioxid snow may also be used for its freezing effect, but
is not so easily handled, as it has to be placed in lumps or balls upon
the parts to be acted upon; it is principally used in this way for other
therapeutic purposes; when so used, its action can be greatly inten-
sified by dropping ether upon it. The injection of cold solutions into
the tissues to obtain a direct action of the cold in this way has been
tried, but such practices, to say the least, are unsurgical, are highly
painful, and produce, if any, but a very ephemeral effect from the
cold, and may be followed by serious consequences.
Cold intensifies the action of all local anesthetics, and is often used
as an adjunct to local methods of anesthesia and will be spoken of in
this connection elsewhere.
WATER ANESTHESIA
Pure water was first used for its analgesic action by Potain, who
introduced it in 1869. The term aquapuncture was applied to these
injections, and they were used extensively in the treatment of neu-
ralgia. Mathieu (1869) and Siredey (1872) also describe this pro-
cedure.
64 LOCAL ANESTHESIA
This injection was used only for its therapeutic effect, and it has
not been recorded whether any analgesia of the overlying skin had
been observed to follow its use or not; however, its action was the
same as that made use of to-day for surgical purposes. The first use
of the hypodermic infiltration of the tissues for surgical analgesia has
been credited to foreign surgeons, particularly Germans; this, how-
ever, as far as the literature can be depended upon, is probably an
error.
W. S. Halsted, in a letter published in the New York Medical
Journal, September 19, 1885, makes the following statement regard-
ing water anesthesia: - r
“(1) The skin can be completely anesthetized to any extent by
cutaneous injections of water.
“(2) I have at times of late used water instead of cocain in minor
operations requiring skin incisions.
“(3) The anesthesia seldom oversteps the boundary of the original
bloodless wheal, but does not always vanish just as soon as hyperemia
supervenes.”
This use of it is again referred to by Prof. Halsted in a personal
communication to Dr. Dawbarn in 1885 (“Water as a Local Anes-
thetic, Its Discovery American and not German,” Med. Rec., 1891,
Dawbarn). It was not, however, until some years later that this
method was brought forward by our German confrères, and it is to
them, notably Liebreich, in his “Anesthesia Dolorosa,” followed
shortly by Schleich, that the credit is due for the thorough application
and study of the method.
Prof. Bartholow, in his “Materia Medica,” as early as 1885, p. 690,
states the following:
“It is a remarkable circumstance that aquapuncture has the
power to relieve pain in a superficial nerve. So decided is this effect
that there are physicians who hold that the curative effect of the
hypodermic injection of morphin is due not to morphin, but to the
water.”
Since its introduction it has been tried and accepted by nearly
all Surgeons using local anesthesia to any extent that a satisfactory
operative analgesia can be secured by the injection of sterile water
alone into the tissues. Just how this analgesia is produced is not
clearly understood, but it is probably due to the imbibition of the
water by the cells of the tissues causing them to swell and thus inter-
fere or prevent the transmission of painful impressions. (See chapters
on Osmosis and Diffusion and Infiltration.)
THE ANESTHETIC EFFECTS OF PRESSURE-ANEMIA 65
This method can be most effectively demonstrated in loose and
relaxed tissues where infiltration can be readily carried out, and is
less Satisfactory when the tissues are compact or dense. The term
“anesthesia dolorosa” is most appropriate to this method, as anes-
thesia is only Secured at the expense of a certain amount of pain or
discomfort of a burning character; this however, is influenced largely
by Certain conditions; it is more marked in dense tissues, when the
injection is rapidly made and when the temperature of the injected
water varies from that of the body; the pain, however, is not severe and
is of short duration, and is followed by an analgesia of about ten to
fifteen minutes’ duration. In the hands of skillful operators, when the
injected water is about body temperature and slowly and gently
infiltrated with a sharp needle, little or no discomfort is complained
of. To obtain the full analgesic effect, it is necessary to infiltrate
the tissues to the point of producing a glassy edema, the skin or
mucous membrane must be infiltrated intradermally and the infiltra-
tion carried down the full depth of the proposed incision; when this
is done analgesia is usually as profound as after infiltration with
the weaker anesthetic solution, but tactility is little or not at all
affected; the after-pain or discomfort is about the same as that follow-
ing the use of other anesthetic solutions, although Gant claims that
the after-pain is less severe and less prolonged than that following
other local methods. The injurious action upon the tissues should,
by reasoning along purely physical grounds, be greater than when
using other anesthetic solutions, which are more nearly isotonic, as
the injection of sterile water causes the surrounding cells to take up
large quantities as well as giving up a large part of their salts, which
certainly should produce profound physical changes in the cells, and
it would be expected that certain reactions or even inflammation would
follow the physical readjustment of the tissues. Gant, who is a great
advocate of water anesthesia in this country, and employs the method
extensively for operations about the anorectal region, denies any
after-inflammatory reaction.
In the experience of the writer, the experimental use of plain
water upon himself, as well as a limited operative experience with the
method, has failed to notice any after-pain or other unpleasant reac-
tion following its use in a very limited way. In opening a furuncle
upon my own face water anesthesia was used for the purpose of study-
ing its action; the water was injected at about body temperature,
and, when slowly injected, caused only a slight burning sensation,
but when the injection was made too rapidly, this burning sensation
5
66 LOCAL ANESTHESIA
was increased, and might, if used on a sensitive person, cause Some
complaint. There was absolute analgesia during the incision and no
after-inflammatory action was observed.
Notwithstanding its demonstrated utility as a practical means of
obtaining a surgical analgesia its use for any but minor Surgical pro-
cedures is hardly to be recommended on physiologic grounds, as it is
known that the use of such hypotonic Solutions as distilled water causes
the cells to absorb large quantities macerating their protoplasm
and may be followed by necrosis.
Experimentally, it has been found that the injection of distilled
water into dogs, at the ratio of Io drams to the pound of body
weight, is followed in a short time by the death of the animals.
Dr. Dawbarn, of New York, after witnessing Prof. Halsted, in
1885, perform minor operations with pure water infiltration, conceived
the idea that the analgesia was due to a purely mechanical separation
of the tissue-cells, and that any agent which could accomplish this
purpose would yield like results. He accordingly undertook a series
of experiments upon himself, injecting sterile air into the tissues
instead of water; although he persisted to the point of producing a very
decided degree of emphysema, there was no diminution in the sensi-
bility of the part.
CHAPTER V
LOCAL ANESTHETICS
THE history of the use of local means of analgesia precedes that
of the use of general analgesics or narcotics. Many of the older
agents or methods have long since been forgotten; some few, such
as cold, in its more improved use, fill an important place in our thera-
peutics of to-day.
Most agents used for this local anesthetic action, except purely
physical means, such as pressure and cold, exert this influence through
their toxic or paralyzing effects upon the tissues and their nerve-
endings. All such agents when absorbed in sufficient quantities
produce the same constitutional effects, though often associated with
other symptoms which may predominate.
So great was the effort to find safe and practicable means of
producing local anesthesia that any agent reported to possess these
properties was at once put to clinical tests, and many found a field
of usefulness, though limited.
The accepted local anesthetics of to-day, of which cocain is the
type, exert this influence through their paralyzing actions upon all
protoplasm, and this action is central as well as local. The con-
stant effort to improve our methods and produce an agent having
less central toxic action while retaining its local effect has lead to vast
improvements, novocain representing the highest attainment in
this direction at the present time, having largely displaced many of
the older agents. How long novocain will hold this place remains
to be answered by future discoveries.
The following is a brief review of some of the many agents used
before and since the discovery of cocain for which a more or less
degree of local analgesia or anesthesia had been claimed.
Carbolic Acid.-The anesthetic action of topical applications of
pure carbolic acid has been long known, but the escharotic action
following its use has limited its employment to the most superficial
of applications on external and exposed parts; its solutions when
injected into the tissues are painful, and, while producing anes-
thesia, are likely to be followed by tissue necrosis. It has been vari-
67
68 LOCAL ANESTHESIA
ously employed in combination with other agents, as with cocain in
“cocain phenate,” at one time put upon the market by Merck, and
was Supposed to be a distinct chemical combination, but it was later
determined to be only a mixture, and to consist of 3 parts of cocain
to I part of carbolic acid. It is now but rarely used.
Various combinations of carbolic acid and oil were also sug-
gested with or without the addition of cocain. While the anesthesia
produced by these combinations was at times intense, the objec-
tionable feature was the tendency of carbolic acid to cause tissue
necrosis, which brought these mixtures into disfavor. They are,
consequently, at present rarely used except by a certain class of
practitioners, who make use of the anesthetic and escharotic proper-
ties of the combination for the injection of hemorrhoids and such
accessible growths as they wish to destroy by these measures, a rather
unsurgical and often dangerous procedure.
Chloroform has been credited with a certain degree of local seda-
tive action following its injection within the tissues. Eulenburg,
in 1867, recommended it for this purpose. Its anesthetic action
is very slight and is preceded by considerable burning pain.
Methoxycaffein is a white amorphous or crystalline powder, used
as a local anesthetic and antineuralgic. It has been recommended
for hypodermic use in doses of about 4 gr., given in the neighbor-
hood of the nerve in neuralgic conditions.
Alcohol.-More recently (1903) alcohol had been brought for-
ward by Schlosser as a highly valuable agent for destroying the
Sensibility of purely Sensory nerves when used as an intraneural
or paraneural injection. Its action is due to the resulting inflammation
and fibrous changes which it induces in the tissues, blocking or de-
stroying the nerve at this point. It was intended originally for use
in neuralgias, especially in the trigeminus, and more recently for use
as a paraneural injection to the Superior laryngeal as a means of
relieving pain in tuberculosis and cancer of the larynx. Particularly
in the trigeminus is its action of considerable duration, often pre-
venting the return of pain for periods of six to eighteen months,
when, as regeneration slowly recurs, the pain usually returns, pro-
vided the original causative conditions still persist.
Reclus at one time, following the suggestion of Billon, used 20
parts of 90 per cent. alcohol in his local anesthetic mixtures (stovain
was the agent used); this was done with the view of prolonging and
intensifying the action of the stovain. (See latter part of this chap-
ter.)
LOCAL ANESTHETICS 69
Dr. Mellish recorded the observation that a finger immersed in
alcohol at –Io? F. produced analgesia, but did not destroy tactility;
here we are probably dealing entirely with the effects of cold. This
use of alcohol, particularly by Reclus in solutions intended for infil-
tration, prompted the author to undertake some experiments upon
himself, with a veiw of determining its action upon some superficial
part where observations could be constantly made. It was intended,
should the knowledge gained be likely to prove useful, to make a more
extensive series of tests, but in view of the results only Io, 20, and 50
per cent. Strengths were used in various ways.
Ten per cent. Solutions in distilled water, when injected intra-
dermally, caused a sharp burning pain for about half a minute, skin
turning slightly pale, later becoming hyperemic. Sensibility slightly
dulled over area, but would not permit a painless incision—normal
Sensibility returned in about two hours, but area remained slightly
hyperemic for several days.
Twenty per cent. Solutions in distilled water gave nearly similar,
though slightly more pronounced, results. As this was the strength
used in his anesthetic solutions by Reclus, it was accordingly com-
bined with local anesthetics; infiltration of this mixture caused,
when injected, a burning pain, nearly as intense as when used in dis-
tilled water alone, but of shorter duration (only a few seconds); this
gave place to anesthesia; the anesthesia, however, seemed no more
intense or prolonged than when the same solution was used without
alcohol, and was followed by hyperemia of about two days’ duration.
Normal salt solution was then used as a diluting agent, but did
not seem to influence the reaction to any noticeable degree; both
were painful and produced hyperemia.
Alcohol, 50 per cent.; distilled water, 50 per cent. (20 minims),
Io.5o P. M. Injection intradermal caused a very short burning pain,
lasting about one minute, produced a wheal about the size of a 5-cent
piece, surrounded by an injected area about as large as a dollar;
center of wheal at point of needle stick is perfectly white and slightly
depressed, and surrounded by a bright red circle. If wheal is not
disturbed by manipulation no sensation is experienced, but when
manipulated with the fingers causes a slight return of burning Sensa-
tion of short duration. It continues to react in this manner for
eighteen minutes.
Depressed white area became immediately anesthetic, but re-
mainder of the wheal only slightly less sensitive than the surround-
ing healthy tissue.
7o LOCAL ANESTHESIA
In thirty minutes the entire wheal, except the white center, has
regained normal sensibility; the center looks as if the skin has been
completely destroyed. After eight hours wheal has entirely disap-
peared, though tissues at that point are slightly thickened. The
central white spot is still absolutely dead to feeling, but is no longer
depressed below surrounding skin and the red circle has disappeared.
After twelve hours slight return of red zone around central white area.
Repeated observations during next ten days showed a gradual enlarge-
ment of red zone, which became quite inflamed and about # inch in
diameter. Central white area shows signs of gradually sloughing out.
Observations discontinued after ten days, with the conclusion that its
anesthetic action depends entirely upon its destructive influence upon
the tissues, and may in the use of strong solutions be followed by
necrosis.
That this does not occur in deep facial injections is probably due
to the high vascularity and nutrition of the parts.
J. L. Corning has used alcohol and chloroform subcutaneously
in studying their anesthetic effect, and found that they produced
considerable pain, but no anesthesia.
“These observations tend to dissipate the expectations of Nun-
nely, of Leeds, who declared that by exposure to the vapor of chloro-
form he had been able to cause sufficient insensibility in a finger to
render the performance of a surgical operation painless.”
Morphin.-A solution of 4 per cent., which has the same freezing-
point as the blood-serum when injected into the tissues, produces
severe burning, then hyperesthesia, followed by analgesia. As the
solution is diluted it rapidly loses its analgesic effect. A solution of
o. I per cent. produces a well-marked wheal, which itches and burns
like the bite of an insect, but not analgesia. This local irritating
influence is felt with Solution as weak as I: Ioo,ooo parts of water.
Bromids of sodium and potassium, when in solutions injected with-
in the tissues, are said to produce a certain degree of analgesia, but
are preceded by an intense degree of irritation.
Chloral has also been credited with similar action.
Brucin in 5 per cent. Solution produces a limited degree of local
anesthesia.
Antipyrin is an agent which possesses mild but sufficiently well-
marked anesthetic, antiseptic, and hemostatic properties to have
claimed for it a decided field of usefulness in the past before the
introduction of better and more active agents, and occasionally is still
employed.
LOCAL ANESTHETICS 7I
Cycloform is isobutyl paramidobenzoic acid and possesses some
local anesthetic properties.
Many agents like thymol, menthol, guaiacol, ichthyol, monotal,
Spirosal, etc., exhibit local sedative or analgesic action when topically
applied, and are useful over inflamed and painful parts, but are not of
especial interest to us here.
Similar sedative or varying degrees of anesthetic action have been
claimed for many other drugs, such as the digitalis group—digitalin,
strophanthin, Convallarin, helleborin, adonidin, and others too
numerous to mention and of no practical value.
There are many combinations of anesthetic agents which have
been upon the market under various trade names; thus, andolin con-
tains beta-eucain, Stovain, and adrenalin; eusemin, a mixture of
cocain and adrenalin; and codrenin, a mixture of cocain, chloretone,
and adrenalin, and many others.
Electric anesthesia is also a medical possibility, both for general
anesthesia as well as for local use, where the general consciousness is
not disturbed; it may promise much for the future.
Since the advent of cocain many local anesthetics have been in-
troduced for which various claims have been made; some have ful-
filled these claims, others have not; some, by virtue of their merits in
general surgery or some special field, will probably always be re-
tained in our armamentarium and find a more or less limited use
according to their special indications, while many, after having been
put through the test of practical clinical application and found want-
ing, will be dropped and likely soon forgotten.
In spite of the many new agents introduced, and the many ad-
vances made in synthetic chemistry, cocain still remains the standard
and most universally employed anesthetic, although it should now be
entirely superseded by novocain for all general Surgical purposes.
In judging the comparative merit of any new claimant for Surgi-
cal favor in the field of local or regional anesthesia, we must ask our-
selves at least three questions:
(1) What are the requirements that we must demand of the
ideal local analgesic or anesthetic, utilizing these requirements as the
basis or standard of comparison?
(2) What are the claims made for the new anesthetic?
(3) To what extent does experience confirm these claims?
To answer the first question we would require of the ideal local
anesthetic:
(1) That it should be efficient in producing a durable, diffusible,
72 LOCAL ANESTHESIA
and maximum analgesic effect with a minim of local tissue dis-
turbance.
(2) That it be non-toxic to the organism when absorbed in the
doses required to obtain the fullest local effect.
(3) That it must be benign in its local action on the tissues, non-
irritating, non-toxic; it should not permanently injure the cellular
protoplasm or interfere with the normal repair of the traumatized
tissues.
(4) It should be absolutely sterilizable by heat.
(5) It should be soluble.
(6) It should be thoroughly compatible with adrenalin.
(7) It should be commercially accessible and available at a reason-
able cost.
After considering the above, and reading the description of the
following anesthetics and the critical and comparative review at the
end of this chapter, it is found that novocain is the Only agent which
comes nearest filling all these requirements; and anesthesin, if put to
equally rigorous tests for purely topical applications, will be found
equally satisfactory in this particular field of usefulness.
PHYSIOLOGIC ACTION OF LOCAL ANESTHETICS
In discussing the physiologic action of the local anesthetics–
cocain and its congenors—we will describe in full only cocain, for what
applies to cocain is equally applicable to almost the entire group;
any differences that exist are slight and vary in degree not in kind.
In discussing the various agents where these differences are of
consequence attention will be called to them.
The earliest record I can find of the use of any coca preparations
for their anesthetic effects is a letter published in the New York
Med. Jour., October 24, 1885, by Dr. W. O. Moore, of New York,
who states that for the past ten years Dr. Fauvel (address not given)
had been using the fluidextract of coca applied to the pharynx and
larynx by a brush or a spray as a local anesthetic of these parts.
Few agents have sprung so rapidly into such general use, and in
so short a time after their introduction been so universally tried
in all departments of medicine. Being a practically new departure
in therapeutics, medical and surgical, it was taken up by specialists
in all lines, and was the first step in the introduction of agents which
were to fill a long-felt want. The literature of the first year or two
following its introduction is teeming with articles on its use, covering
a wide range of subjects.
LOCAL ANESTHETICS 73
As early as the last half of 1885 the New York Medical Journal
contained twenty-eight separate articles and several editorials on its
uses; articles in other journals were equally as numerous. It was, as
would be expected, already claiming its mortality from injudicious
use and the cocain habit was even then reported.
Some of the interesting papers, even at this early time, taken
from the above-mentioned list, are “Cocain Anesthesia in Supra-
condyloid Osteoma and Excision of the Hip-joint” (by Roberts);
“Cocain as A Remedy in Seasickness; As an Anesthetic in Fractures
and Dislocations; In Hay Fever, Opium Addiction, Sore Nipples,
Vaginismus, Whooping-cough; As A Means of Isolation of the Tem-
perature Sense in the Oropharyngeal and Nasal Cavity.” In the
treatment of facial neuralgia, gynecology, labor, nervous affections,
and in the eye and ears, as well as numerous cases of minor surgery,
it would be difficult to-day to conceive of a more extended use of the
drug; we have improved the technic and manner of its use, but
certainly have not extended the field.
COCAIN
Cocain (methyl benzoyle.cgonin), C.Hi,(CH.)NCH(OCOCH.)-
(CH,COOCHA).
The alkaloid and hydrochlorate are the only two preparations
official in the United States and British Pharmacopeias; the oleate .
and ointment are mixtures.
Many salts of cocain have at times been put upon the market
by the manufacturers in the hope of producing a better preparation
than the hydrochlorate, but none have so far fulfilled these claims
except for special purposes. Most of these preparations are true salts,
Some are double salts, and a few are found to be only mixtures.
Cocain aluminum citrate and cocain aluminum Sulphate are astrin-
gent preparations, and are intended for topical applications; the borate
has antiseptic properties, and has been particularly advocated as an
eye-wash; its hypodermic use is at times irritating.
Cocain cantharidate has been recommended for hypodermic use
in certain forms of nasal catarrh and for tubercular conditions of
the upper air-passages and larynx; its use causes a mild inflammation
which, through the increased blood-supply to the parts, had been
hoped to favor curative processes in these lesions; it is not often
used; the carbolate, as mentioned elsewhere, is a mixture; the lac-
tate has been recommended as a sedative application and injection
in cystitis; the nitrate has a particular field of usefulness in gonor-
74 LOCAL ANESTHESIA
rheal inflammations and for combination with some of the many
silver salts used in this infection; the phosphate is a useful preparation,
but is not very soluble and has little to recommend it; cocain saccha-
rate has been suggested for topical applications and for use in throat
and mouth operations; the Salicylate was at one time advocated for
use in asthma; it is now rarely used, its continued employment may
lead to a habit; the stearate is a mixture used for topical applications,
for suppositories and ointments, but is now rarely used.
The alkaloid was first isolated by Gardeka in 1855, who named it
erythroxylin, but renamed slightly later by Niemann, who made a
much fuller investigation concerning its action. It began to be used
in medicine as early as 1880 in a very limited way, although its dilat-
ing effect upon the pupil had long been known. It was not, how-
ever, until 1884, when brought forward by Koller, that its true value
began to be known, and it came very shortly into general use. This
immediate increased demand for the drug far exceeded the limited
facilities for its manufacture, and had the effect of markedly increas-
ing the price, which is reported to have risen as high as $3 per grain;
as the manufacturing facilities developed this price rapidly fell in a
few years to one cent per grain, and has since been further decreased
by improvements in the method of manufacture as well as a steadi-
ness of the supply. During the early days of its use the methods of
manufacture and purification were very imperfect, and led to its
admixture with many impurities, giving rise often to serious acci-
dents when used about the eye and to a misinterpretation of its nor-
mal action. The synthetic preparation of the drug has been another
means of reducing the cost of manufacture, as well as having led to the
discovery of many valuable synergistic drugs which have proved
highly valuable.
Tests.-The following tests have been offered as a means of de-
termining its purity:
Maclagan's: Dissolve I grain of cocain hydrochlorate in 2 ounces
of distilled water, to which add I or 2 drops of ammonia solution;
after stirring for a few minutes, if free from amorphous cocain, cocain
hydrate will separate from the solution in crystalline form and settle
at the bottom, leaving the supernatant solution clear and free from
opalescence, any cloudiness indicating the presence of amorphous
cocain.
Gartier's: Mix I drop of a 2 per cent. Solution of permanganate of
potassium with a solution of cocain hydrochlorate (2 cgm. to o.5 gm.).
The resulting fluid must assume a red color and remain transparent.
LOCAL ANESTHETICS 75
To this solution add drop by drop more of the permanganate solu-
tion, when there should appear a red precipitate of permanganate of
cocain; this should become brown only after heating and without
giving off an odor of bitter almonds. If the addition of I drop of the
permanganate solution produces a brown color or brown precipitate,
or when on heating the mixture there is produced an odor of bitter
almonds, the preparation is impure and unfit for use.
Physiologic Action.—Cocain exercises a universal action on all
living protoplasm, first stimulating and then paralyzing it; this action
applies to plant as well as animal protoplasm.
Locally applied cocain acts as a very decided anesthetic, as
first brought out by Moreno Y. Maiz, in 1862, and later by Von
Anrep, in 188o.
The soluble salts of cocain are absorbed with great rapidity;
they pass with the greatest facility through nearly all mucous mem-
branes, and are taken up with an almost equal rapidity from de-
nuded surfaces, but are not absorbed from the intact skin. The
above fact explains the large number of cases of serious poisoning
which have resulted from its use on mucous surfaces.
Extensive researches, undertaken to study the action of cocain
upon the vital manifestations of various kinds of cells of animal
life, was made by P. Albertoni. According to the concentration of
the solution and the duration of its action, it either stimulates or
paralyzes all cells in their functional activities. A o.25 per cent. Solu-
tion applied to the palate of a frog stimulates markedly the activity
of the ciliated epithelium, so that particles of colored dust are moved
aßng at four times their normal rate, while 2 per cent. Solutions so
paralyzes this action that it amounts to one-fourth or one-sixth the
normal rate of movements. Similar experiments were conducted
upon other kind of cells or low animal life, such as grubs, Spermato-
zoids, and the large blood-cells of some animals, as well as the white
blood-cells of man, all showed a similar action, being stimulated by
weak solutions when acting for a short time, later being paralyzed.
Muscle-fiber, when similarly treated, fails to respond either to nerve
or electric stimulation. A peculiar action of cocain upon the livers
of mice was brought out by the studies of Ehrlich, who fed mice food
containing a small quantity of cocain, which killed them after a few
days; examination showed their livers increased in volume and look-
ing much like stuffed goose livers. Microscopic examination showed
a vacuolar degeneration of the cells with Small fragments of proto-
plasm about the nucleus; the blood-vessels showed fatty degeneration;
76 LOCAL ANESTHESIA
the connective tissue was undergoing fatty degeneration with points
of coagulation necrosis. No glycogen was found in the entire livers.
Its action upon the nerve-tissues cannot, therefore, be strictly re-
garded as of a specific kind, as it exercises this same action upon
protoplasm generally, although its action upon nerve-tissue may be
of a more marked degree, as manifested upon the end-organs of sen-
sory nerves or upon the conductivity of their trunks when injected
intraneurally, which constitutes one of the most marked and striking
properties of cocain, and enables it to claim the high position which
it holds as a therapeutic agent.
The well-known vasoconstrictor action of cocain, when brought
in contact with the vessel walls by direct application or injection into
the tissues, can only be explained by a direct action upon the Smooth
muscle-fibers within the vessel walls. This action is also seen, but to
a less degree, when the drug is given constitutionally, when it is
seen to raise the blood-pressure, but in large doses this influence
upon the vessels is overshadowed by the greater powers of the drug.
In the early days of its use the anesthetic action of the drug was
erroneously attributed to the ischemia that its injection caused, as it
was known then that ischemic tissues were less sensitive than when
in a normal state. It may be possible that the anesthetic influence
is slightly affected by this ischemia, but this action must be very
slight, and it is also further disproved by the fact that since the
introduction of cocain other anesthetic agents have been discov-
ered which exert little or no influence upon the vascularity of the
part, and some even producing vasodilation, yet with marked anes-
thetic action.
If the sequence of the phenomena are closely observed following
the local application of cocain (say to the cornea), it will be found
that the anesthesia precedes the anemia by a short interval of time.
As demonstrated by Mosso and amply confirmed by others, as
well as by daily clinical observation, cocain locally applied suspends
the activity of motor nerves, although sensory nerves are first and
more decidedly influenced; applied to the nerves of special sense,
where these nerves are accessible for experimentation, has caused
them to lose their particular function, sight, smell, or taste being
lost during the action of this agent. Tumass has been able to demon-
strate that it exercises this same influence when applied to the cerebral
cortex. The motor areas of dogs were exposed by trephining, then
cocainized, using solutions up to 4 per cent strength; after these
applications it was found that the stimulation of these areas barely
LOCAL ANESTHETICS 77
produced any response; the full effect of this action lasted for fifteen
minutes, and required forty-five minutes to entirely disappear.
Alms also experimented by injecting it into the iliac artery of a
frog, in this way carrying it to the entire distribution of this vessel
in the lower limb, bringing about complete paralysis of the entire
limb. This was the first attempt at arterial anesthesia. (See chapter
on this subject.)
It is generally stated by all observers that after large doses injected
into the general circulation the sensory nerves are finally paralyzed,
but that doses not dangerous to life have very little effect upon the
general sensibility. This statement may, however, prove only par-
tially correct, as in this connection we would like to call attention
to the experiments by Kast and Meltzer, discussed in the opening part
of the chapter on Abdominal Surgery, and to its general anesthetic
action, as demonstrated by Ritter and Harrison; also to the obser-
vation by Ott, that in a certain stage of cocain-poisoning irritation of
the central end of the cut sciatic causes no response, while irritation
of the distal end excites muscular action.
Central Nervous System.—The higher centers are first stimulated,
making ideas flow freer; laughing, singing, or loguacity are also usually
produced, associated with a feeling of joy, happiness, or bouyancy,
which are the usual causes which encourage addiction to this drug;
these sensations are followed by mental hebetude, dullness, or a
sense of fatigue. Respiration is always stimulated, large doses pro-
ducing dyspneic breathing, increasing to tetanic convulsions of the
respiratory muscles followed by paralysis in fatal doses.
According to Dodd, very distinct histologic changes can be demon-
strated in the nerve-centers after poisoning and that these lesions
are most marked in the cerebral cortex. While Verebily and Hor-
vaith have been able to demonstrate nearly similar changes in nerve-
tissue following its local action, this, however, as ordinarily used must
be of temporary effect, for of the many thousand cases in which cocain
has been used there are comparatively very few, and most of these
spinal puncture cases, in which there has been any serious results or
permanent changes following its use, it is most likely that in many
of these cases impure or non-sterile solutions were used or the technic
faulty.
The action of cocain upon the heart and vascular system is rather
complicated, and many points regarding its action here are far from
settled. However, it may be fairly safely stated that small or medium
doses stimulate the force and frequency of the heart action and
78 LOCAL ANESTHESIA
raise the arterial tension by contracting the peripheral arterioles.
When a solution of cocain is applied to the eye there occurs first a
contraction of the pupil followed by a dilatation in a few minutes.
This initial contraction is no doubt reflex, the result of mechanical
irritation, or due to the acid reaction of the solution. With medium
strength solution (4 per cent.) the maximum dilatation is reached in
an hour, and begins to decline by the end of the second hour, requiring
from twelve to twenty-four hours to return to normal. The dilated
pupil is slightly responsive to light and to accommodation; the dilata-
tion can be increased by atropin and very rapidly overcome by eserin.
This mydriasis is due to a peripheral influence, and is the result of
stimulation of the sympathetic nerve-endings, for when this nerve
is first divided in animals and the injection then made these symptoms
do not appear. Cocain is capable of producing a very decided rise
in temperature, sometimes to as much as 8° F. in cases of poisoning;
as reaction takes place this is followed by a fall before death. Reich-
ert, in a series of experiments, has been able to determine that this
rise was due to a stimulation of the thermogenic centers in the caudate
nucleus, as well as to motor excitement the result of stimulation of
the motor centers. Considerable variation has been encountered
by different investigators regarding the renal secretory function;
however, it is generally conceded that cocain markedly lessens the
elimination of urea, and single large doses have produced an anuria
sufficiently prolonged to bring on uremic symptoms.
The secretion of the saliva and perspiration is lessened by its
local or constitutional action, due to its influence in constricting
the peripheral circulation.
Intestinal peristalsis is increased by moderate doses, large doses
paralyzing the intestines and rendering them hyperemic. The ultimate
fate of cocain within the body is at present uncertain; when large
doses have been used a small quantity, about 5 per cent., has been
recovered from the urine, but it is no doubt very largely destroyed
in the body and broken up into its molecular constituents.
EUCAIN
The discovery of eucain was the first decided advance in the field
of synthetic chemistry to crown the efforts of the many investiga-
tors laboring to discover a less toxic agent than cocain.
This, like other anesthetics to be discovered later, is a benzoyl
derivative. Alpha-eucain or eucain a was the first discovered. This
however, was found to be too irritant and did not meet with much
LOCAL ANESTHETICS 79
favor. Efforts on the part of synthetic chemists (Vinci, 1897) soon led
to the discovery of eucain b, or beta-eucain, which eliminated the irri-
tant qualities and reduced the toxicity. Eucain a was soon entirely
displaced and is now no longer manufactured. All the eucain to be
obtained is now of the beta kind; this is chemically benzoyltrans-
vinyldiaceton-alkamin and is closely related to tropacocain.
The free base of beta-eucain is almost insoluble in water, but its
acid salts (hydrochlorate are fairly soluble 3.5 per cent.). This
limited solubility is a decided disadvantage and led to the introduc-
tion of eucain lactate, which is soluble to 22 per cent. and slightly
less toxic, due to its containing a slightly lesser quantity of eucain,
Ioo parts, compared to hydrochlorate, 119. The lactate is a white
hygroscopic powder of decidedly bitter taste.
The various degrees of solubility of the two salts is given as fol-
lows at ordinary temperature:
Hydrochlorate. Lactate.
In water. . . . . . . . . . . . . . . . . . . 3.5 per cent. 22 per cent.
In alcohol. . . . . . . . . . . . . . . . . 3.5 { { II { {
In chloroform . . . . . . . . . . . . . I5.O & & 2O & 4
In glycerin. . . . . . . . . . . . . . . . . 2.O & & 5 ( &
The solubility of the hydrochlorate is slightly increased by warm-
ing, and, as it does not precipitate immediately, increased strengths
can be used in warm solutions. Extensive chemical experience with
this drug proves that when injected hypodermically for surgical pur-
poses it is practically non-irritant, but produces a slight vasodilata-
tion. Compared with cocain it is slightly weaker in action, 1.5 per
cent. Solutions equaling in intensity and duration the action of a I
per cent. Solution of cocain.
Regarding its toxicity, a point on which its claims for preference
largely depend, investigators are not all of one opinion. Vinci and
many others claim it to be three to five times less toxic than cocain,
and this would seem to be borne out by the extensive clinical tests
to which the drug has been submitted, in which few if any cases of
poisoning have been reported. However, the careful investigations
of Piquand and Dreyfus (see latter part of this chapter on the com-
parative study of the different anesthetic agents) give beta-eucain a
toxicity very slightly less than cocain. Further points in the action
of eucain are that it is slightly slower in action and slightly less
diffusible than cocain. Investigations seem to clearly prove that it
possesses well-marked but slight antiseptic action, and to possess the
particularly desirable quality of being capable of being boiled with-
8o LOCAL ANESTHESIA
out effecting its efficiency, and its solutions may be kept for con-
siderable time without suffering deterioration. This agent, while
possessing many advantages over cocain, was yet far from proving
thoroughly satisfactory to the earlier operators, largely due to the
resulting hyperemia, which frequently gave rise to troublesome
after-hemorrhage; this was particularly the case in dental surgery.
After the introduction of adrenalin in 1900 this disadvantage was
practically entirely overcome, and the agent came into more ex-
tended and general use. -
Following the advent of adrenalin, the advantage of a com-
bination with eucain was quickly recognized by the pioneer workers
in the field of local anesthesia, notably Braun, Matas, and Barker,
who utilized solutions of eucain and adrenalin for the performance
of an extensive range of major surgical procedures, Matas devising an
ingenious infiltrating apparatus for edematization of the operative field.
The following solution, recommended by Braun, became very
popular:
Beta-eucain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
NaCl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Aqua. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOO.O
This solution, capable of boiling, could always be rendered thor-
oughly sterile, its keeping qualities adding another advantage. The
adrenalin was always added to the solution just before use, estimating
the total quantity likely to be used, and adding to this the necessary
amount of adrenalin. .
Barker’s solution was very similar to that of Braun's, but both
have the disadvantage of being too weak for satisfactory use for anes-
thetizing the skin, unless it is thoroughly edematized also for block-
ing large nerve-trunks; for these last-mentioned purposes it is better
to employ solutions slightly stronger (about o.4 per cent.), but for
infiltration of all subcutaneous tissues the Braun solution is found
thoroughly satisfactory. It is necessary, however, for a delay of ten
or fifteen minutes after the infiltration before beginning the operation,
to allow the solution ample time to thoroughly saturate the tissues
and exert its maximum anesthetic effect.
In special fields of work eucain has proved highly satisfactory,
more particularly in the nose, although here it has not been univer-
sally adopted, and it has never seriously threatened cocain in oph-
thalmology, though possessing some few advantages here.
In the nose the ischemia produced by cocain is at times a dis-
advantage, whereas, under the use of eucain, this disadvantage does
LOCAL ANESTHETICS 8I
not occur. Instilled into the eye its solution causes mild hyperemia,
but does not produce dilatation of the pupil or loss of accommoda-
tion, and its use is not followed by the changes in the corneal epi-
thelium sometimes produced by cocain; notwithstanding these ad-
vantages, the anesthesia which it produces has not been thoroughly
satisfactory, and it has never become very popular with ophthal-
mologists. This agent, in its time the most satisfactory substitute
for cocain for use in general Surgery, and marking a decided advance
in the progress of local anesthetics, has now been largely superseded
by novocain, which possesses all the advantages claimed for eucain
with others in addition.
AKOIN
Closely related to holocain is a white crystalline powder of bitter
taste. The hydrochlorate is soluble in water to 6 per cent., and freely
so in alcohol. It possesses decided antiseptic qualities. It is decom-
posed by alkalis. Compared with cocain, it is slightly slower and
weaker in action and slightly more toxic, and its poisonous action is
of longer duration. It, however, possesses the particular quality of
producing prolonged anesthesia, sometimes lasting several hours. Its
injection is quite irritating, strong solutions decidedly so; 5 per cent.
Solutions are said to have caused necrosis. As ordinarily recom-
mended, in o.20 to o.5 per cent. Solutions, its injurious action is not so
manifest, but even these weak solutions frequently leave behind a
slight painful induration. Possessing as it does the power of producing
a prolonged anesthesia, it at one time enjoyed considerable popular-
ity, but since the introduction of adrenalin this advantage is not so
apparent. It was particularly combined in weak solutions with
other anesthetics, thus utilizing some of its desirable qualities while
preventing its primary irritation, and greatly prolonging the post-
operative anesthesia. These qualities were particularly desirable in
all operations about the anus, hemorrhoids, etc.
HOLOCAIN
Holocain hydrochlorid, a synthetic preparation introduced into
medicine in 1897, is derived from the same source as phenacetin,
with which it is often adulterated. It is decomposed by alkalis, but
stands a moderate degree of boiling. It is moderately soluble in
water, and more toxic than cocain. Its action is quite irritant, fol-
lowed later by anesthesia. Owing to its irritant action it is rarely
used for infiltration, but finds its principal field of usefulness in ocular
surgery. When instilled into the eye in I per cent. Solution, the
6
&
82 LOCAL ANESTHESIA
strength usually advised, it produces a moderate degree of burning,
followed in about fifteen seconds to one minute by anesthesia, which
lasts about ten to twenty minutes. Its particular claims for useful-
ness here are its decided antiseptic qualities; it does not affect the cir-
culation or produce corneal drying as does cocain, does not produce
mydriasis, affect accommodation or intra-ocular pressure; these
qualities make it valuable in treating corneal ulcerations and in re-
moving foreign bodies from the eye; in these latter cases as it does
not control hemorrhage as does cocain is considered in its favor, as
the escaping blood often washes away bacteria which might other-
wise gain an entrance into the tissues. Notwithstanding its irritant
qualities, its other desirable features, when used in the eye in com-
bination with its dual properties of anesthesia and antisepsis, de-
mands for it a certain place in ophthalmologic Surgery.
An investigation undertaken at the Johns Hopkins Hospital to
determine its value as an antiseptic arrived at the following conclu-
sions: It exerts a distinct antiseptic influence upon ordinary pus-
organisms and the Micrococcus epidermidis albus. No attempt was
made to determine the exact point of time in which these organisms
lose their vitality when exposed to I per cent. Solutions, but it is some-
where around twenty-four hours, but these organisms were found to
grow on agar containing o.5 per cent. holocain.
TROPACOCAIN
This agent, benzoyl-tropein, was first isolated from the coca plant
of Java by Giesel, and studied physiologically by Chadbourne, who
ascribes to it an action identical with cocain, except that it is of
much quicker action and of shorter duration than cocain and is
about one-half as toxic; it produces no change in the vascularity of
the tissues with which it is brought in contact. Toxic symptoms aris-
ing from its use are usually of much shorter duration than those
produced by cocain. When instilled into the eye in watery solution
it produces anesthesia of the cornea in about one-half the time neces-
Sary for similar Solutions of cocain, but producing no ischemia or
paralysis of accommodation and but slight mydriasis; the anesthesia
is slightly less intense than that produced by similar strength solu-
tions of cocain.
It has little to commend it for general use, and has consequently
not become very popular, but seems to be more suited to spinal
analgesia than any other agent so far introduced, as fewer sequelae
or fatalities have followed its use in this field.
LOCAL ANESTHETICS 83
STOVAIN
A derivative of the benzoyl group, first introduced by Tourneau
as a Substitute for cocain, is a white powder easily soluble in water;
its Solutions stand a limited amount of boiling, but are decomposed
when heated to 120° C.; it is said to be unsuited to combination
with adrenalin.
The French School by which this drug was introduced have been
particularly active in pushing it forward, notably Tuffier and Reclus.
It was especially recommended for spinal puncture, in which it was
at One time extensively used. After a more extended use its irritating
qualities, especially to nerve-tissues, becoming more apparent, it has
been less used than formerly. For especial consideration of the
changes induced in nerve-tissue, consult chapter on Spinal Analgesia.
A claim advanced for it in spinal analgesia is that it induces a
greater relaxation of all the sphincteric outlets than is accomplished
by the use of any other agent. It is generally conceded as being
slightly less toxic and less powerful than cocain and its anesthesia of
slightly less duration; its toxic symptoms when manifest are very
similar to those induced by cocain. Its dilute solution, injected
into the tissues, causes a slight burning pain, which is soon followed
by anesthesia and frequently leaves a postanesthetic inflammatory
reaction; strong Solutions up to Io per cent. are very likely to be
followed by tissue necrosis. Sinclair reports this occurrence follow-
ing the use of a 2 per cent. Solution. It has been tried in the eye, but
has not met with much favor here owing to its irritating qualities.
This agent will be discussed more at length in the latter part of this
chapter, in the comparative study of the action of the different anes-
thetics.
ALYPIN
Introduced in 1905 by Impens, is of rather complex chemical
formula, a derivative of the benzoyl group, and closely related to
stovain; is a white crystalline powder of neutral reaction, easily soluble
in water and alcohol, sparingly so in ether, not decomposed by moder-
ate boiling nor precipitated by moderate quantities of sodium bicar-
bonate. This agent was introduced as a substitute for cocain to
overcome some of the unpleasant effects of the latter; in this it has
been only partially successful. The results obtained by the investi-
gations of the German school of investigators on the one hand, and
the French and English on the other, do not entirely agree in all
particulars regarding the toxicity and action of this agent. The
84 LOCAL ANESTHESIA
Germans claim it to be non-irritant and less toxic than cocain, while
the French and English claim it to be irritant and slightly more toxic
than cocain. Our personal observations in the use of this agent rather
incline us to lean to the French and English view. For the result of
the comparative study of this and other agents, consult the latter
part of this chapter. Regarding its anesthetic power it is about equal
to cocain, and is especially recommended for Ophthalmic, nose, and
throat surgery, although it finds certain indications for use in general
surgery; thus, Schleich combines it with cocain in his three anes-
thetic solutions, reducing the cocain in each one-half and adding an
equal quantity of alypin; by this combination lessening the toxicity
of each as well as enhancing the total anesthetic effect, according to
Burgi's contention, explained elsewhere in this volume. While the
combination of different anesthetic salts in solution is thoroughly
rational and has certain advantages, if such combinations were to be
made we would much prefer the use of novocain to alypin. The in-
jection of solutions of alypin as ordinarily used at times causes a
slight burning, and is followed by Some hyperemia, and in some cases
slight inflammation has followed its use; this, however, is less marked
than with stovain. Compared with cocain it exercises about an
equal anesthetic power, but of slightly less duration; this is probably
due to the ischemia induced by cocain retarding absorption, while
the hyperemia induced by alypin favors it; this can, however, be
overcome by the addition of adrenalin, with which alypin is thor-
oughly compatible.
Instilled into the eye, its 4 per cent. Solution causes a slight burn-
ing followed by anesthesia in about twenty-five seconds, and in one
minute this anesthesia is sufficiently profound to permit the cureting
of corneal ulcers, their cauterization, the removal of foreign bodies,
and other Superficial operations. Its advantages within the eye are
that it does not cause drying of the corneal epithelium, dilatation of
the pupil, or changes in accommodation or tension.
In the nose and throat, but more particularly in the nose, are
its advantages sometimes apparent, particularly in the removal of
posterior hypertrophies of the turbinates, where the shrinkage induced
by cocain is sometimes a decided disadvantage; the same advantages
are noticed with polypi; further advantages claimed for it are that
its taste is not so bitter as cocain, and it does not cause the same
sensation of choking or lump in the throat, which is sometimes annoy-
ing to nervous patients. Some operators claim an advantage for it
when used without adrenalin for the removal of tonsils, as it does not
LOCAL ANESTHETICS 85
cause a vasoconstriction; any hemorrhage that will occur takes place
at the time of operation and not postoperative. -
Prof. Bransford Lewis has especially recommended it for use in
the posterior urethra and bladder as a means of anesthesia prepara-
tory to cystoScopy, using for this purpose specially prepared tablets
containing I; gr. of the drug; these are deposited in the posterior
urethra with a special depositor, and, after allowing time for the
tablet to be softened by the mucus, the mass is then smeared over
the adjacent membrane by a to-and-fro movement of the depositor.
He claims that this agent gives thorough satisfaction when used in this
way, requiring about five or ten minutes to produce sufficient anes-
thesia for the introduction of the cystoscope.
Dr. Willy Meyer also recommends it in the genito-urinary tract,
but uses instead of the tablet instillation of a 2 per cent. solution.
Providing the claims of a lesser toxicity of this agent as compared
with cocain had been thoroughly established, it might readily find a
more extended use, but from our experience we must regard it as
fully as toxic; it, nevertheless, finds a certain field of usefulness for
special work, particularly in the eye, nose, and throat. Where silver
nitrate is to be applied to mucous surfaces and external parts, alypin
nitrate has been introduced by the manufacturers as a substitute for
the plain salt, which to some extent neutralizes the effect of silver
nitrate through chemical decomposition. This is not the case with
alypin nitrate, and its anesthetic effects are not destroyed by the ap-
plication of silver nitrate; its chemical characters, solubility, and
strength of Solutions essentially correspond to those of alypin.
NOVOCAIN .HYDROCHLORID
With the introduction of this agent the ceaseless efforts and
zealous endeavors of the numerous workers in the field of synthetic
anesthetics has at last been crowned with a very decided degree of
success in obtaining an effective agent absolutely non-irritant and of
low toxicity, which qualities are of vital consideration for the general
use of a local anesthetic. Some of the many substitutes for cocain
already introduced have exhibited advantages in one or the other
direction, but none of them have fulfilled all of the prime considera-
tions, particularly those of lack of toxicity and irritating qualities,
which in some of these agents has been so marked that their strong
solutions produce almost a corrosive action. The absence of irritating
Hualities in novocain is most marked, even when applied in powder
form or concentrated solution to sensitive wounds in the most deli-
86 LOCAL ANESTHESIA
cate tissue and on such surfaces as the cornea. Novocain, which is
the hydrochlorid of para-aminobenzoyldiethylaminolthanol, is a white
crystalline powder of neutral reaction and possesses the formula:
sh.
/CN
HC CH
| |
HC CH
NC/
COO.C.H.N(C.H.).; HCl, was introduced by Einhorn in 1905.
It is soluble in water I to 1 and in alcohol in I to 3o; it melts at 156°C.
and can be heated in 120° C. without decomposition. Its solutions
possess slight antiseptic properties, and are capable of repeated boil-
ings without apparently affecting their strength, and may be kept for
long periods of time (several months), a quality not possessed by any
of the other anesthetic agents, without apparently suffering any change
in its action.
Like other agents of this group its solutions are precipitated by
alkalis and alkaline carbonates, with the exception in favor of novo-
cain that it is not precipitated or its solutions rendered turbid by
sodium bicarbonate. * -
The physiologic investigation of novocain shows that it pro-
duces no mydriasis, no disturbances of accommodations, and no
increase in intra-ocular pressure. The effect of moderately large
doses upon the general system, when absorbed by either the intra-
venous or subcutaneous route, show almost no perceptible change
either upon the circulation or respiration, and practically no changes
were observed in the blood-pressure or respiration when studied by
the kymograph. Numerous investigations by competent observers
regarding its relative toxicity (see latter part of this chapter) all
agree in giving it a toxicity from one-fifth to one-seventh of that of
cocain, while studies made to determine its relative activity seem
to show 1.25 per cent. Solutions equal in anesthetic activity to 1 per
cent. Solutions of cocain, though possessing a slightly shorter duration
of action; while, on the other hand, this agent when combined with
adrenalin solutions possesses the highly desirable quality of having
its action greatly intensified, more so than that of any other similarly
used agent, to such an extent that solutions of equal strength equal
in activity those of cocain, though slightly slower in action, but often
yielding an anesthesia of longer duration than equal strengths of
cocain similarly used.
LOCAL ANESTHETICS 87
Injected within the tissues, even in strong solution, novocain
exerts but little or no influence upon the vasomotors of the part; its
injections are without pain and seem to be absolutely free from all
irritation; no after-pain, inflammation, hyperemia, or induration has
been observed to follow its action. It is further claimed for novo-
cain that where it is necessary to make repeated use of this agent that
no danger of the formation of a habit need be anticipated.
The remarkably favorable action obtained by the combination of
adrenalin preparations with novocain, as well as its total absence of
all irritation, is well shown in the following experiments of Prof.
Braun, published in the “Deutsch. Med. Wochenschrift,” 1905, No. 42:
“I. Isotonic solution of novocain (o.1 per cent.). Formation of a cutaneous wheal
on the forearm. Injection painless. The anesthetic action, like that of tropacocain, was
of very short duration, and in from three to five minutes cutaneous sensibility returned.
No hyperemia. The wheal vanished without leaving a trace.
“2. Solutions of novocain (o.5 and I per cent.). Formation of cutaneous wheals.
Injection painless. Duration of wheal anesthesia fifteen minutes. Wheals vanished
leaving no trace. No hyperemia.
“3. Solutions of novocain (5 and Io per cent.). Formation of wheals. Injection of
5 per cent. solution painless; Io per cent. solution produced very slight irritation. Dura-
tion of anesthesia seventeen and twenty-seven minutes, respectively. Very slight hy-
peremia at site of injection. Wheals vanished. No infiltration or tenderness remained.
“4. Novocain solution (1 per cent.). I c.c. injected subcutaneously into forearm
in region of superficial radial nerve. Soon after the skin over the injected area showed
diminished sensibility. No distinct evidence that the peripheral nerve-twigs were anes-
thetized.
“5. Novocain solution (o.5 per cent.). Constriction of little finger with rubber tube.
Injection of I c.c. of solution circularly into the subcutaneous tissue of the first phalanx.
After eleven minutes entire finger completely insensible. Rubber tubing removed. In
five minutes sensibility had returned. No swelling or sensitiveness remained in finger.
“We have to do, therefore, with a local anesthetic with a strong, yet in comparison
with some others, a transitory action, like that of tropacocain. In order to obtain results
comparable with those from cocain, it would be necessary to use concentrated solutions
and large doses in proportion to the slight toxicity of novocain. However, this necessity
is readily and successfully overcome by the addition of suprarenin to the novocain Solu-
tions.
“6. Isotonic novocain solution (o.1 per cent.). To Ioo c.c. add 5 drops I : Iooo
suprarenin solution. Formation of cutaneous wheals on the forearm. Injection painless.
Very marked anemia. Duration of anesthesia more than an hour. No reaction of any
kind.
“7. Novocain solution (1 per cent.), each cubic centimeter of which contained 2
drops of suprarenin solution I : Iooo. Formation of wheals on forearm. Anesthesia ex-
tended far beyond limits of wheals. Duration nearly four hours. Marked suprarenin
anemia, upon subsidence of which some after-pain. No other reaction.
“8. I c.c. of the same solution injected beneath skin of forearm. The skin over the
site of injection, as well as in the course of the sensitive nerves, was anesthetic for two
hours. Marked suprarenin action. No reaction.
“9. Novocain solution (o.5 per cent.) with addition of I drop of suprarenin solution
(I : Iooo) to each cubic centimeter; I c.c. injected beneath the skin of the first phalanx of
88 LOCAL ANESTHESIA s
the fourth finger. In ten minutes finger anesthetic and anemic. Sensibility began to
return in sixty-five minutes. Another hour elapsed before complete return of sensibility.
No after-pain.”
The conclusion of Braun's observations are that novocain ac-
tually increases the action of adrenalin, while Biberfeld, after studying
the same subject, states that novocain is the only local anesthetic
which does not arrest or weaken the action of adrenalin. Our own
observations on this subject, drawn from a large number of clinical
cases, is not thoroughly in accord with those of the above investiga-
tions on some few points—viz., we have never observed the same
degree of ischemia of the tissues when working with our solution No. 1
(o.25 per cent. novocain) plus 15 to 20 drops of adrenalin (I: Iooo) to
each 3 or 4 ounces of solution, as when using equal quantities of
adrenalin with similar solutions of cocain, although the intensity of
anesthesia was fully equal to that produced by the cocain Solutions
and the duration of its anesthesia often longer.
Novocain has not become universally popular for purely topical
applications in the nose and throat, although it always succeeds Satis-
factorily when used for infiltration, especially in combination with
adrenalin. It is probable that the failure of Some operators to secure
satisfactory results from its local application in the concentrated
solutions (Io per cent.) usually used for this work is due to the fact
that insufficient time has been allowed for its absorption, as it is
somewhat slower in action than cocain; but, in view of its much re-
duced toxicity, its action here should be encouraged, as it is in this
particular field that so many toxic cases occur.
Its action in the genito-urinary tract, urethra and bladder, has
proved fully as satisfactory as that of any other similarly used agent
when a slightly longer time has been allowed for its action.
Novocain nitrate has been introduced for especial use within the
urethral tract and elsewhere when silver nitrate and other silver
salts are to be used, as it is compatible with combinations of silver.
It is particularly recommended for employment with the various
silver salts for urethral injections, using the novocain nitrate in I to 3
per cent. Solutions in combination with Such agents as albargin, pro-
targol, etc.
For reference to its other methods of use here, see chapter on
General Technic, as well as the chapters on the special subjects.
Thus far the observations made with novocain in ophthalmologic
practice rather point to the conclusion that cocain will still remain
the anesthetic of choice in this particular field, due largely to the
LOCAL ANESTHETICS 89
slowness of action of novocain and its inability to penetrate and anes-
thetize the tissues deeply following topical applications. However,
certain advantages possessed by it over cocain are the absence of
drying and injury to the superficial corneal epithelium so often noted
following the use of cocain. This was studied by Gebb on the cornea
of rabbits, holding the eye open by self-retaining speculi and treat-
ing the eye with Io per cent. Solutions of novocain; after twenty min-
utes absolutely no change could be noted in the epithelia, which was
in marked contrast to the effects noticed following the similar use of
cocain. When dropped into the eye in powder form slight transitory
changes were noted which had entirely disappeared after two hours,
while cocain similarly employed may be followed by more lasting or
Serious changes, sometimes terminating in leukoma. -
Notwithstanding the advantages possessed by it, due to its com-
parative lack of irritation, cocain when cautiously and carefully used
still remains the agent of choice in this field.
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.
We, therefore, feel thoroughly justified in unqualifiedly recommend-
ing it as the safest, most reliable, and satisfactory of any local anes-
thetic agent yet introduced.
Novocain base (soluble in oils) has also been put upon the market,
and is intended for special uses where oily preparations are to be
employed.
CHLORETONE
Chloretone was discovered in 1881 by Willgerodt, and sug-
gested as a substitute by him for chloral in 1884. It was, however,
not until 1897 that its active manufacture was undertaken by Hoff-
man, La Roche & Co.
It is formed by the action of potassium hydroxid upon acetone
and chloroform; the result of this action is a white camphoraceous
powder, first called aneson or anesin and later renamed chloretone.
It is soluble in warm water to I per cent., o.8 per cent. in cold water,
quite soluble in oils and glycerin, and very soluble in alcohol, ether,
benzin, glacial acetic acid, chloroform, and acetone. It is a very
stable chemical compound and is unaffected by heat or light. It is
quite compatible in mixtures of bichlorid of mercury, carbolic acid,
thymol, etc.
It is particularly an antiseptic, local anesthetic, and hypnotic.
90 LOCAL ANESTHESIA
It was expected that a drug possessing such valuable chemical and
therapeutic properties would prove highly useful, but in this respect
it has not fulfilled the expectations of the profession.
Internally administered, it readily passes into the circulation
and is decomposed within the body, as none of it can be recovered
from the urine or expired air. In large doses chloretone causes in
lower animals a profound sleep, associated with complete and pro-
longed anesthesia; this occurs without marked effect on respiration,
heart action, or blood-pressure. This sleep may sometimes last several
days and the animal awake unharmed, but if too large a dose is ad-
ministered death will occur from asphyxia after two or three days'
sleep.
One inconvenience regarding its administration is its insolubility
in ordinary menstruums; it is, however, fairly safe and 20 to 40 gr.
can be administered to an adult at one time.
When locally applied to denuded areas it first exerts an irritant
action, followed in a short time by a very decided degree of anes-
thesia; injected hypodermically into the tissues it is quite irritating,
but is followed by marked anesthesia, the site of the injection remain-
ing for Some time as a painful induration. According to Kossa and
Vamossy, it possesses greater anesthetic powers than cocain, but
is slower in action and less penetrating. They state that a 1 per cent.
solution equals in activity a 2.8 per cent. Solution of cocain. This
remarkable statement has, however, not been confirmed by others.
However, its undesirable irritating action condemn it as a useful local
anesthetic, nevertheless possessing many desirable qualities; combin-
ing marked anesthesia with antisepsis and hypnosis it will always en-
joy a fair range of usefulness.
Its anesthetic action is manifested along the gastro-intestinal
tract, where it proves a valuable gastric sedative, and, possessing as it
does decided antiseptic properties, is quite useful in such conditions
as gastric ulcer and gastric irritation, with emesis from other causes,
such as Seasickness, and as a preventive to nausea incident to
general anesthesia; when used for this purpose it should be given in
Io- to 15-gr. doses about one hour before anesthesia. It has been
stated by Hirschman that in cases so treated very few are nauseated
after the anesthetic, and that few, if any, vomit during the anesthesia;
its further advantages during this state are due to its hypnotic quali-
ties, which lessens the quantity of the anesthetic used and prolongs
the anesthetic sleep. Locally applied, chloretone would suggest itself
as applicable to a multitude of Surgical conditions, such as ulcers,
LOCAL ANESTHETICS 9I
burns, wounds, hemorrhoids, rectal fissures, insect bites, etc., particu-
larly so owing to the facility with which it lends itself to combination
in solutions with other antiseptics as well as in powders; the disap-
pointing feature, however, is its irritating properties, which at times
are quite marked, while in other cases this is not so apparent, its
anesthetic action quickly setting in. We have used it repeatedly for
burns, and in nearly all cases with very happy results; as it is very
slightly soluble, it remains in action for some time. It is best used in
Solution, poured over the dressings as often as the occasion demands,
its antiseptic action greatly lessening the surface infection; if the
dressings are kept constantly wet the irritant action is rarely com-
plained of, as the anesthetic action is maintained. Its absolute innoc-
uousness, even in large doses, renders its a safe application even for
large surfaces; any effect exercised from its absorption will be hyp-
nosis, rather a desirable action, in many cases lessening or entirely
removing the need for narcotics. Irritable ulcers and chancroids
similarly treated often prove very satisfactory. As a postoperative
Sedative it may prove useful in circumcision, hemorrhoids following
the use of the cautery, and many other conditions, either in Solution,
ointment, or dry upon the wound; incorporated in gauze, it proves
useful in packing irritable wounds; it may also occasionally prove use-
ful as an application to painful cancerous ulcerations.
In nose and throat surgery it finds a field of usefulness in sprays
for ulcerated and inflamed conditions or upon packs following opera-
tion.
It also serves a use in dentistry, exercising its antiseptic and
anesthetic qualities in excavations, alveolar abscess, etc.
It was tried in combination with other anesthetics in spinal anal-
gesia and reported on by Stone, who cites 200 favorable cases, but
it is hardly to be recommended here owing to its irritant action.
Owing to this unfortunate quality it has largely been superseded
by other agents, notably anesthesin, but its greater Solubility and an-
tiseptic properties will always claim for it a certain range of useful-
IleSS.
ORTHOFORM
Orthoform, nirvanin, anesthesia, and subcutin were produced
largely as the results of the efforts of the synthetic chemists to de-
termine if the complete cocain molecule was necessary to produce
anesthesia, as well as to see if by certain changes in this molecule the
toxicity could be reduced. Orthoform (old) is a white powder, almost
insoluble, and possessing decided anesthetic properties when brought
92 LOCAL ANESTHESIA
into contact with exposed nerve-endings, such as are found on raw
and denuded surfaces, as in wounds, ulcers, gastric vesical; and rectal
lesions, etc. When in contact with Such surfaces its insolubility ren-
ders it active for a long time unless washed away. This agent pos-
sesses decided antiseptic properties, which, combined with its anes-
thetic power, claimed for it an extensive range of usefulness in oint-
ments and powders to burns, ulcerated surfaces, chancroids, etc.,
for which it came into rather extensive use until its toxic action
began to be reported when too extensively used, or in certain cases
apparently possessing idosyncrasies.
This led to the introduction by Einhorn, in 1897, of orthoform
(new), which is meta-amido-para-oxybenzoic-acid-methylester. In
this preparation an attempt was made to eliminate the objectionable
toxic qualities of orthoform (old), these efforts were, however, only
partially successful, as irritant and toxic symptoms, though, as a rule,
less severe and less frequent, began to be reported from the new
preparation. One advantage which this agent possesses is the ready
facility with which it lends itself to combinations with many other
drugs, being thoroughly compatible with, bichlorid of mercury,
carbolic acid, iodin, Salicylic acid, calomel, and many other prepara-
tions. - -
It also found a rather extended field of usefulness for many in-
ternal as well as external conditions, being used for lesions about
the nose, throat, and larynx with the same facility as in those of the
exposed parts.
Toxic symptoms, which, however, not very frequent, would
occasionally develop, were for the most part mild, but occasionally
were severe, and brought this agent into disfavor.
The disturbances likely to arise from the use of orthoform mani-
fest themselves as a dermatitis with more or less severe constitutional
reaction, and occasionally loss of tissue at the point of application.
These symptoms may arise from a few days to several weeks after
the powder has been in use, and frequently come on abruptly in cases
where the powder had previously given perfect satisfaction; its action
in this respect and symptoms are very similar to those occasionally
encountered with iodoform.
The symptoms generally begin by more or less burning, Smarting,
or pain in the wound or at the site of application, a pustular derma-
titis develops about the wound and elsewhere over the body asso-
ciated with itching, elevation of temperature; rapid pulse and pros-
tration may be noted in the severe cases; there is often a sticky dis-
LOCAL ANESTHETICS 93
charge of a peculiar branny or doughy odor which takes place from
the wound, and this is occasionally accompanied by loss of tissue in
the severe cases.
Since the advent of anesthesin, which possesses none of the ob-
jectionable features of Orthoform, is thoroughly tolerated and non-
irritant and practically non-toxic, this agent has now been almost
entirely supplanted.
NIRVANIN
Nirvanin, of rather complex chemical formula, is a soluble form of
orthoform, introduced by Einhorn and Heinze in 1898, is a white
powder, of neutral reaction, easily soluble in water, and possessing
antiseptic as well as anesthetic qualities, and is not decomposed by
heat. Luxenburger, who investigated this substance, found it to be
much less poisonous than cocain and fixed the maximum dose at 8
gr. Its injection causes some burning pain, while no injurious
action on the tissues have been reported. It leaves behind a slightly
tender hyperemic area. It is about one-tenth as powerful as cocain,
and the duration of its action is much shorter. Its feeble action
prevents its being used effectively as a topical application to mucous
membranes; its irritant action makes it objectionable in the eye. At
first it was thought that it would become very popular and largely
supersede cocain, but it is now rarely used.
ANESTHESIN
Two notable advances were recorded in the pharmacology of local
anesthetics in the introduction of anesthesin for purely topical ap-
plication and novocain for infiltration. These agents possess so many
valuable qualities that they threaten to largely supersede the use of
all other agents, particularly in general surgery. Anesthesin is ethyl-
para-amido-benzoate, and was introduced in 1890 by Ritsert, to whom
we already owed much in the synthesis of local anesthetics. The need
for a new substance was felt in the disappointing qualities Sometimes
exercised by orthoform, which anesthesin was intended to replace;
that this want has been well filled is evidenced by the tremendous
satisfaction expressed on all sides wherever anesthesin has been used.
This agent is a fine, white crystalline powder, melting at 90° C., almost
insoluble in cold water, but slightly so in hot water, easily soluble in
alcohol, ether, benzin, and fatty oils (in the latter from 2 to 3 per cent.).
It is not decomposed by a moderate amount of heat, but is by pro-
longed boiling, as well as by heating it with alkalis. The particular
94 LOCAL ANESTHESIA
qualities of this drug are that it is absolutely non-irritating, almost
non-poisonous, and possesses decided anesthetic qualities. In animal
experimentation by Binz, in which large doses were given to rabbits,
it was found to exert no injurious action, very large doses producing
a transient methemoglobinemia, but no renal irritation or methemo-
globinuria. These facts, with numerous clinical data, in which large
doses (30 to 40 gr. daily) have been given internally without no-
ticeable bad effect, would tend to prove that it possesses very mild
toxic properties.
Regarding its physiologic activity anesthesin very closely parallels
orthoform, but is superior to it in some ways, as it exerts a decided
influence on intact mucous surfaces; its insolubility requires a few
minutes for it to exert its full influence.
Experiments and numerous clinical observations have proved
that anesthesin is tolerated by even the most delicate tissues without
the slightest irritation; it can, therefore, be applied quite freely to all
kinds of fresh operative wounds, burns, ulcers, chancroids, etc.,
without producing the least irritation or other unpleasant after-effects.
Internally it is highly useful in all forms of gastralgia, ulcer of the
stomach or hyperesthesia, vomiting of pregnancy, etc. In the nose,
throat, and larynx it finds a very decided field of usefulness, as in-
sufflations, inhalations, painting as well as in the form of pastils, in
tuberculous, syphilitic, and cancerous ulcerations, also in many
acute inflammatory conditions. In a series of experiments on patients
suffering from tubercular laryngitis conducted by Prof. von Noorden,
in which the drug was used in Io per cent. emulsions, 3 per cent. solu-
tions (water with 45 per cent. alcohol) and by insufflations, all three
methods gave relief, but the insufflations proved most satisfactory.
In the auditory canal, for the many inflammatory conditions of
these parts, after a preliminary cleansing, the insufflation of the powder
or its use in strong oily emulsion often affords very gratifying relief.
The full effect of anesthesin is noted in about ten minutes, and on
external surfaces, where it remains undisturbed, this action persists
for from several hours to a day.
In genito-urinary surgery it may also prove quite useful when
used in emulsion, or as soluble pencils in vesical irritation, due to
hyperesthesia, ulcer, tuberculoses, or malignancy or as a palliation in
stone, and in similar form within the urethra in combination with
other remedies.
In all operations about the rectum it is highly useful, as well as
in the palliative treatment of such conditions as ulcers, fistula, painful
LOCAL ANESTHETICS 95
hemorrhoids, or anal pruritus. Following operations in this region the
free use of the preparation as a powder, or 20 per cent. ointment, will
relieve almost entirely all postoperative pain. Following the use of
the cautery on chancroids or phagadenic ulcers it will allay any
after-burning. For irritable and painful chancroids we have found
nothing better. A marked illustration of the benefits of this agent
were seen in a case of chancroids which, during self-treatment, was
severely burned with pure carbolic acid as well as the entire head of
the penis; the patient was in great distress, nearly frantic from the
pain; all measures which had been tried had failed to give relief.
Strong solutions of cocain afforded some benefit, but was too transient
and seemed to increase the inflammation, besides producing symptoms
of absorption; at this juncture the case was seen by one of us, and pure
anesthesin powdered over the parts; relief was complete in about
five minutes and lasted for about six hours, when the application was
repeated. Under this treatment no further pain was complained of
and the wound healed in about the usual time.
Applied in Io per cent, ointment form to the skin it has proved
highly useful in allaying the pain of erysipelas and pruritus from toxic,
diabetic, nephritic, and other causes, also in the intense irritations
sometimes seen in cases of urticaria.
Solutions of the acid salts of anesthesin had been used for hypo-
dermic use for infiltration with but little success, as during the trans-
formation into acid salts some irritating qualities seem to be de-
veloped.
In conclusion, we may say that, after an extended use of this
agent in a great variety of conditions, we have never yet been disap-
pointed where sedative topical applications would be expected to give
relief.
SUBCUTIN
Subcutin is a soluble anesthesin introduced by Ritsert, and formed
by the action of paraphenolsulphuric acid upon anesthesin; it is said
to be germicidal and non-toxic. It is obtained as a white crystalline
powder of acid reaction, soluble in water up to I per cent., and not
decomposed by boiling. Its injection is painless, anesthesia taking
place at once, but it is stated by some observers to be followed by
considerable inflammatory after-effect. It is a much less powerful
anesthetic than cocain and of shorter duration. Its irritant action
(like anesthesin) when injected makes it little used for infiltration.
96 LOCAL ANESTHESIA
PROPASIN
A white crystalline powder of neural reaction, almost tasteless and
odorless, slightly soluble in water, easily so in alcohol and ether,
melting at 74° C. It forms salts with mineral acids and is decom-
posed after prolonged boiling with alkalis.
It is recommended for use in dermatology and in the gastro-
intestinal tract. Used as an ointment, Io to 15 per cent., upon the
skin, and after being rubbed in it produces at first a feeling of prick-
ing, followed shortly by anesthesia of prolonged duration; it is recom-
mended as a dressing for ulcers, pruritus, etc.
In the form of pastils it has been suggested for Sore throat and
internally for gastric ulcers. It is said that after about ten minutes the
pain leaves and a numbness sets in which lasts about two hours. The
internal dose is 2 or 3 gr. which can be repeated Several times daily
without any apparent harmful effect.
COMPARATIVE ACTION OF ANESTHETIC AGENTS
The most thorough and careful investigation of the comparative
action of the different anesthetic agents and their relative toxicity
has been undertaken by Piquand and Dreyfus. Their first investiga-
tion was on the toxicity of different mixtures of cocain and stovain,
and was undertaken in 1907 and reported to the Society de Biologie.
In this investigation rabbits and guinea-pigs were used, and the
injections slowly and uniformly made in all cases.
The following are the results of these investigations:
INTRAVENOUS INJECTIONS IN RABBITs
Stovain:
Rabbit, 3 kg. (.150), death with 9 cg. (.5), or o.o.301 per kilo of animal.
Rabbit, 2 kg. (.870), death with 8 cg. (.5), or o.o.299 per kilo of animal.
Cocain:
Rabbit, 2 kg. (.975), death with 4 cg., or o.org.8 per kilo of animal.
Rabbit, 2 kg. (.850), death with 5 cg. (.5), or o.o.192 per kilo of animal.
Rabbit, 3 kg. (.150), death with 6 cg., or o.org per kilo of animal.
Stovain (#), cocain, I part to 200 dilution:
Rabbit, 3 kg. (.150), death with 8 cg., or o.o.266 per kilo of animal.
Rabbit, 3 kg. (.150), death with 9 cg., or o.o.285 per kilo of animal.
Rabbit, 2 kg. (.5oo), death with 7 cg. (.5), or o.o.3 per kilo of animal.
Stovocain and cocain, each I to 200:
Rabbit, I kg. (.900), death with 4 cg. (.25), or o.o.25 per kilo of animal.
Rabbit, I kg. (.930), death with 6 cg., or o.o.31 per kilo of animal.
Rabbit, I kg. (870), death with 5 cg., or o.o.26 per kilo of animal.
LOCAL ANESTHETICS 97
INTRAPERITONEAL INJECTIONS IN THE GUINEA-PIG
Cocain:
Guinea-pig, 62o grams, death with 5 cg. (.2), or 8 cg. (.3) per kilo of animal.
Guinea-pig, 6oo grams, survived with 4 cg. (.5), or 7 cg. (.5) per kilo of animal.
Guinea-pig, 73o grams survived with 6 cg., or 8 cg. per kilo of animal.
Stovain:
Guinea-pig, 420 grams survived with 8 cg., Or IQ C9. per kilo of animal.
Guinea-pig, 520 grams, survived with 9 cg., Or I7 Cg. per kilo of animal.
Guinea-pig, 430 grams, death with 8 cg. (5), or 19 cg. per kilo of animal.
Stovain (#), cocain, I part to 200 dilution:
Guinea-pig, 4oo grams, death with 9 cg., or 22 cg. (.5) per kilo of animal.
Guinea-pig, 7oo grams, survived with 9 cg., or 12 cg. (.5) per kilo of animal.
Guinea-pig, 540 grams, death with 9 cg. (.2), or 17 cg. per kilo of animal.
Guinea-pig, 51o grams, survived with 7 cg. (.75), or 15 cg. per kilo of animal.
Guinea-pig, 48o grams, survived with 7 cg. (.75), or 16 cg. per kilo of animal.
Stovain and cocain, each I part to 200:
Guinea-pig, 930 grams, survived with 12 cg. (.5), or 13 cg. per kilo of animal.
Guinea-pig, 7oo grams, death with Io cg. (.5), or 15 cg. per kilo of animal.
It will be seen from a careful perusal of the foregoing that stovain
is about three-fourths as toxic as cocain, at least for the smaller
animals, and that by using mixtures of the stovain and cocain that
much larger total quantities could be used than would have been the
case with either agent alone. This last point is of practical interest
in bearing out Burgi's contention spoken of elsewhere in this book,
and made use of by Schleich, who now combines alypin with cocain
in equal quantities in all his local anesthetic solutions.
The following is drawn from investigations by the same authors
(Piquand and Dreyfus), and appeared in the “Jour. Phys. et Path.
Gen.,” for January, 1910:
“Comparing cocain with stovain on peripheral nerves and on the
cornea of animals they found that in the same strength and quantities
stovain was slower in action and of shorter duration than cocain–
twenty minutes as compared to twenty-five.
“Comparing tropococain with alypin in the eye of animals, it was
found that with equal quantities of the same strength solution alypin
was slightly slower in action and of somewhat longer duration than
tropococain—twenty minutes as compared to fifteen. The eye
treated with alypin was slightly inflamed for forty-eight hours after-
ward.
“Comparing cocain with stovain injected intradermally gave
about the same comparative results as when used on peripheral nerves
or in the cornea. Comparing tropococain with alypin intradermally,
7
98 LOCAL ANESTHESIA
tropococain anesthesia (I per cent) takes place immediately and per-
sists nineteen to twenty minutes.
“Alypin (1 per cent.) at the end of two to three minutes, and lasted
twenty to twenty-two minutes, the skin remaining red and painful for
several hours afterward.
“Novocain (1 per cent.) gave immediate complete anesthesia for
twenty minutes. Novocain (5 per cent.), with I drop of adrenalin
solution (1 per cent. per cubic centimeter), gave an immediate anes-
thesia with anemia that persisted a very long time. At the end of one
hour the skin was insensitive to pricking and pinching.
“In clinical use cocain (1:200) in Reclus’ solution produced anes-
thesia after two to three minutes, lasting fifty to sixty minutes;
I per cent. Solution gave an anesthesia lasting eighty to ninety min-
uteS.
“In less concentrated solutions (1:400) anesthesia was obtained
in six to seven minutes, but often incomplete, its effect passing off
after twenty to thirty minutes; I : Iooo solution, as recommended by
Schleich, gave unsatisfactory results.
“Solution I: 200 when kept in prolonged contact with mucous
membranes produced anesthesia. Stovain in clinical use in equal
strength as cocain was found to be less effective and of shorter dura-
tion. M. Billon found o.75 per cent. Solution of stovain equal to
o.5 per cent. Solution of cocain.
“Stovain in pure watery solutions was often found to be painful
and the development of anesthesia somewhat delayed; in physiologic
salt solution its action was more prompt.
“To augment the degree and duration of the action of the stovain
solution Billon recommends either the combination with cocain or
alcohol:
Alcohol (90 per cent.). . . . . . . . . . . . . . . . . . . . . . . . . . . . 2O C.C.
Aq, dest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 c.c. (os)
Stovain. . . . . . e e º 'º e º e º e º s º a º e º e s e º g g g : te (.50)
Anesthesia produced by this solution is superior to that of stovain
in pure watery solutions, but clearly inferior to cocain in o.5 per cent.
solutions.
“Clinical experiments with beta-eucain showed it to be less active
and of shorter duration than that produced by cocain.
“In clinical experiments tropococain was found to produce a
slightly longer anesthesia than stovain. Novocain was found to pos-
sess anesthetic properties superior to stovain and tropococain and
almost equal to cocain. In pure watery solution of 5 per cent. it was
LOCAL ANESTHETICS 99
very slightly painful, but not at all so in normal salt solution—its
anesthesia was of short duration, about twenty-five minutes.
“In two patients operated upon in which one-half the field was
anesthetized with cocain and the other half with novocain, each I: 200
solution, the following observations were made: The injection of
each was painless; in the fields infiltrated with cocain the anesthesia
appeared slightly quicker than the half infiltrated with novocain;
in one there was no difference in the intensity of the anesthesia; in
the other there was a slight difference in favor of cocain; in each the
anesthesia was slightly longer in the cocain half of the fields.
“In Several patients anesthetized partly with stovain and partly
with novocain, each I: 200 solution, the injections of stovain were
always slightly painful, while the novocain injections were always
painless, more rapid and more complete in action, but the stovain
anesthesia was maintained slightly longer.
“Two patients anesthetized partly with novocain and partly with
cocain-stovain (in equal parts) each presented a perfect, complete
anesthesia, but more durable in the cocain-stovain field.
“A patient, anesthetized one-half the field with novocain and the
other half with tropococain I: 200, presented an anesthesia more
complete with novocain, but more durable with tropococain.”
To augment the durability of novocain anesthesia, Reclus has
suggested the following:
“Normal salt solution. . . . . . . . . . . . . . . . . . . . . . . . . . . Ioo grams
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 centigrams
Adrenalin (I: IOOO solution). . . . . . . . . . . . . . . . . . . . 25 drops.
With this mixture, in an experience of over 3oo cases, anesthesia was
immediate, complete, and lasted in general over an hour.”
The comparative value of the agents experimented with is given
as follows:
(1) Cocain, the most efficient.
(2) Novocain-adrenalin, nearly equal in power to cocain, but more
durable.
(3) Novocain, alypin, and coca-stovain in equal parts; these three
have an anesthetic power nearly equal but less durable for novocain.
(4) Stovain, tropococain, beta-eucain; these three about equal.
They hold the same general opinion as all experienced observers,
namely, that the toxicity of cocain and its substitute depends upon
the concentration of the solution and the rapidity with which it is
injected and taken into the general circulation. The same dose
Ioo LOCAL ANESTHESIA
that will kill an animal when injected intravenously in concentrated
Solution can be given subcutaneously in dilute solution without
noticeable ill effects; or, if injected in concentrated solution and its
absorption delayed through constriction, its toxic action is weakened
proportionate to the delay.
“(1) By injecting into the vein of a rabbit weighing 2 kg. (.330)
a solution of cocain I: 200 in such a way as to control the flow to
5 c.c. per minute, the animal died when it had received 15 cg. of the
alkaloid or 6 cg. (.4) per kilogram of weight.
“(2) By increasing the flow to Io c.c. per minute in a rabbit
weighing 9 kg. (.130) death occurred when it had received 9 cg. of
the alkaloid or 4 cg. (.2) per kilogram of weight.
“(3) By diminishing the flow to 5 c.c. per two minutes in a rabbit
weighing 3 kg. (.200) death occurred when the animal had received
20 cg. of the alkaloid or 9 cg. per kilogram.
“Similar experiences were had with cocain, stovain, and tropo-
cocain, and demonstrates the law given by Reclus that the toxicity
of the drug depends upon the quantity introduced into the circulation
and reaching the central nervous system at the same time.
“By administering the drug in interrupted doses or by delaying
its absorption it is possible to administer three or four times the toxic
dose without injury.
TOXICITY
“All injections were made in the vein on the ear of the rabbit, using
Solutions of I: 200 strength, with the Roger apparatus, which regulated
the flow to 5 c.c. per minute.
I. Cocain:
Rabbit, 2 kg. (.975), death with 4 cg., or .oré8 per kilo of animal.
Rabbit, 2 kg. (.850), death with 5 cg. (.5), or .org.2 per kilo of animal.
Rabbit, 3 kg. (.150), death with 6 cg., or .org per kilo of animal.
2. Stovain:
Rabbit, 3 kg. (.150), death with 9 cg. (.5), or .0301 per kilo of animal.
Rabbit, 2 kg. (.870), death with 8 cg. (.5), or .oz.99 per kilo of animal.
Rabbit, 2 kg. (.300), death with 8 cg. (.7), or .030 per kilo of animal.
3. Stovain-ocain (#), 1 to 200:
Rabbit, 3 kg., death with 8 cg., or o.266 per kilo of animal.
Rabbit, 3 kg. (.150), death with 9 cg., or .oz85 per kilo of animal.
Rabbit, 2 kg. (.5oo), death with 7 cg. (.5), or .03 per kilo of animal.
4. Stovain-cocain, each I to 200:
Rabbit, I kg. (.700), death with 4 cg. (.25), or .oz.5 per kilo of animal.
Rabbit, I kg. (.930), death with 6 cg., or .031 per kilo of animal.
Rabbit, I kg. (.870), death with 5 cg., or .o.26 per kilo of animal.
LOCAL ANESTHETICS IOI
5. Beta-eucain:
Rabbit, 2 kg. (.900), death with 5 cg. (.5), or .or87 per kilo of animal.
Rabbit, 2 kg. (.800), death with 5 cg. (.5), or .org6 per kilo of animal.
6. Tropococain:
Rabbit, 2 kg. (.900), death with 5 cg. (.8), or .oz per kilo of animal.
Rabbit, 3 kg, (..Ioo), death with 6 cg., or .org per kilo of animal.
Rabbit, 2 kg. (.8oo), death with 6 cg. (.1), or .oz.2 per kilo of animal.
7. Alypin:
Rabbit, 2 kg. (.600), death with 4 cg. (.5), or or 55 per kilo of animal.
Rabbit, 2 kg. (.850), death with 5 cg. , or .or 78 per kilo of animal.
Rabbit, 3 kg. (.oso), death with 5 cg. (.5), or .org.z per kilo of animal.
8. Novocain:
Rabbit, 2 kg. (.330), death with 15 cg., or .oé4 per kilo of animal.
Rabbit, 2 kg. (.328), death with 15 cg. (.5), or offé per kilo of animal.
Rabbit, 2 kg. (.380), death with 14 cg. (.5), or .05 per kilo of animal.
9. Novocain (1 to 200) and I drop of adrenalin solution (I: Iooo) per 2 c.c.:
Rabbit, 2 kg. (.150), death with 20 c.c. of the sol., or 4 cg. (.6) of novocain per kilo of animal.
Rabbit, I kg. (.950), death with 17 c.c. of the Sol., or 4 cg. (.5) of novocain per kilo of animal.
Rabbit, 2 kg. (.250), death with 25 c.c. of the Sol., or 5 cg. (.1) of novocain per kilo of animal.
Rabbit, 2 kg. (..Ioo), death with 20 c.c. of the sol., or 4 cg. (.7) of novocain per kilo of animal.
Io. From the above the following relative averages of toxicity were obtained:
I cg. (.7) per kilo of animal for alypin.
I cg. (.83) per kilo of animal for cocain.
I cg. (.9) per kilo of animal for beta-eucain.
2 C9. per kilo of animal for tropococain.
2 cg. (.7) per kilo of animal for stovain and cocain equal parts.
2 cg. (.83) per kilo of animal for stovain and cocain (# parts).
3 C9. per kilo of animal for stovain.
4 cg. (.6) per kilo of animal for novocain-adrenalin.
6 cg. (.3) per kilo of animal for novocain.
INTRAPERITONEAL TOxICITY IN THE GUINEA-PIG
I, Cocain, I per cent.:
Guinea-pig, 62o grams, survived with 5 cg. (.2), or 8 cg. (.3) per kilo of animal.
Guinea-pig, 6oo grams, survived with 4 cg. (.5), or 7 cg. (.5) per kilo of animal.
Guinea-pig, 73o grams, survived with 6 cg., or 8 cg. per kilo of animal.
2. Stovain, I per cent.:
Guinea-pig, 420 grams, survived with 8 cg., Or IQ C9. per kilo of animal.
Guinea-pig, 520 grams, survived with 8 cg., or 17 cg. per kilo of animal.
Guinea-pig, 430 grams, death with 8 cg., Or IQ C9. per kilo of animal.
3. Stovain and cocain (#), 1 per cent.:
Guinea-pig, 7oo grams, survived with 9 cg., or 12 cg. (.5) per kilo of animal.
Guinea-pig, 540 grams, death with 9 cg. (.2 ), or 17 cg. per kilo of animal.
Guinea-pig, 51o grams, survived with 7 cg. (.75), or 15 cg. per kilo of animal.
Guinea-pig, 48o grams, survived with 7 cg. (.75), or I6 cg. per kilo of animal.
4. Stovain and cocain, each I per cent.:
Guinea-pig. 930 grams, survived with 12 cg. (.5), or 13 cg. per kilo of animal.
Guinea-pig, 7oo grams, death with Io cg. (.5), or 15 cg. per kilo of animal.
Guinea-pig, 7oo grams, death with Io cg. (.5), or 15 cg. per kilo of animal.
Guinea-pig, 570 grams, survived with 7 cg. (.5), or 13 cg. per kilo of animal.
IO2 LOCAL ANESTHESIA
5. Novocain, I per cent.:
Guinea-pig, 595 grams, with 19 cq. per kilo showed no trouble.
Guinea-pig, 357 grams, with 20 cp. per kilo showed no trouble.
Guinea-pig, 362 grams, with 3o cg. per kilo showed no trouble.
Guinea-pig, 372 grams, with 4o cg. per kilo showed no trouble.
Guinea-pig, 55o grams, with 5o cg. per kilo became very ill.
Guinea-pig, 35o grams, with 60 cy. per kilo, death.
Guinea-pig, 510 grams, with 5o cg. per kilo, death.
6. Novocain-adrenalin (1 per cent.) with I drop of adrenalin (I:Iooo) per 2 c.c.:
Guinea-pig, 360 grams, with 3o cg. per kilo showed no trouble.
Guinea-pig, 375 grams, with 4o cg. per kilo showed no trouble.
Guinea-pig, 420 grams, with 45 cg. per kilo became ill.
Guinea-pig, 5oo grams, with 5o cg. per kilo, death.
“From the above experiments the following comparisons were
drawn for the relative toxicity of intraperitoneal injections:
8 cg. (.15) per kilo of animal for cocain.
I4 C9. per kilo of animal for cocain-stovain (#).
16 cy. (5) per kilo of animal for cocain-stovain (#).
I9 C9. per kilo of animal for stovain.
5O C9. per kilo of animal for novocain.
5O C9. per kilo of animal for novocain-adrenalin, 25 drops.
“Novocain was almost three times less toxic than stovain and six
times less toxic than cocain. What was particularly important was
that novocain-adrenalin was notably more toxic than novocain alone
only in intravenous injection, but was not more toxic in intraperitoneal
injection.
“Subcutaneous injections on various animals show that novocain-
adrenalin is not appreciably more toxic than novocain alone.
“Action on the Tissues.—Cocain when injected into the tissues
causes no pain or inflammation and is absorbed without leaving
behind any trace of its action. When instilled into the eye it causes
no pain or alteration in the cornea. It has a marked vasoconstrictor
action.
“Concentrated solutions when instilled into the eye cause a momen-
tary burning pain. This is more marked with some preparations than
with others, and is probably due to slight differences in the method
of manufacture.
“Stovain when instilled into the eye causes a marked sensation,
as of a foreign body, lacrimation, and photophobia, the vessels becom-
ing injected with moderate contraction of the pupil. Injected intra-
dermally and subcutaneously it provokes pain lasting two to three
minutes.
LOCAL ANESTHETICS IO3
“The lacrimation, photophobia, and congestion produced by the
instillation of stovain in the eye, and when injected into the tissues
the pain and vasodilatation indicated an irritation due to its acid
reaction.”
German authors, particularly Braun, insist upon this irritant
action of Stovain and cite 4 cases, observed by Sinclair, in which gan-
grene of the tissues followed the use of a 2 per cent. solution. But
Reclus, in an experience of over 3000 cases with stovain in 1.5 per cent.
Solution, did not see a single such accident, and when used on the dog
and rabbit in Io and 15 per cent. solutions did not see a trace of
gangrene. Clinically, it produced a slight irritation of moderate
duration.
“(3) Beta-eucain, injected subcutaneously, causes a sharp pain
which lasts several minutes. Instilled into the eye it causes lacrima-
tion, photophobia, and a persistent redness. These phenomena
of irritation are notably more marked and more durable than with
Stovain. -
“(4) Tropococain, when injected into the tissues, is not irritating,
and has no effect upon the vessels. Instilled into the eye of the
rabbit it causes a slight lacrimation and redness of the conjunctiva.
“(5) Alypin is extremely irritant; intradermal injection of I per
cent. Solution are painful, and accompanied by marked redness and
vasodilatation. Following the injections the tissues remain painful
and infiltrated for a long time. Five per cent. Solutions are extremely
painful, and may be followed by gangrene. Instilled into the eye in
5 per cent. Solutions causes pain, lacrimation, photophobia, redness of
the conjunctiva, and transient paralysis of accommodation.
“(6) Novocain does not appear at all irritant; with injections of
o.5 or I per cent. there is no vasoconstriction or vasodilatation and
leaves no after-effect upon the tissues. Injections of Io per cent.
are slightly irritant and produce slight congestion of the tissues; this
rapidly disappears and does not leave behind any appreciable lesion.
Applied to the mucous membranes on tampons it produces a rapid
anesthesia without any disturbing effects upon the tissues. When
instilled into the eye it causes no disturbance; if a little of the pure
drug is dropped on the cornea it causes a slight irritation of short
duration; if pure cocain is dropped on the cornea it produces pro-
nounced disturbances.
“(7) Novocain and adrenalin (1:200 with I drop of adrenalin
Solution I: Iooo to each 2 c.c.) do not appear to be more irritating
than novocain alone, and cause no disturbance either at the time of
IO4 LOCAL ANESTHESIA
the injection or afterward. With the adrenalin it produces prolonged
anesthesia and a pronounced vasoconstriction, lasting for several
hours. These conclusions were drawn from an experience of over
3oo cases. In this series there was, however, 3 cases of gangrene,
which occurred during a change of staff, and it is presumed was due to
some error in the technic of sterilization or preparation of the fluid, as
no similar cases had been reported except 2 cases by Strohe (“Deut-
sche Zeit. f. Chir.,” T. x, C. T. x, p. 264), but in these 2 cases the
quantity of adrenalin was very large.
“From the above observations the following conclusions were
drawn. Cocain is the most powerful of all local anesthetics, but its
high toxicity renders it dangerous; a safe dose should not exceed
14 to 15 cg. in 1:200 solution, care being taken to maintain the recum-
bent position during and after its use. -
“Six cases of death occurred from the use of cocain, in one the
dose was 28 cg. in 2 per cent. Solution.
“Beta-eucain appears to present no advantage over cocain; it is
equally as toxic, much less anesthetic, and more irritant.
“Alypin should be proscribed in view of its toxicity and irritating
qualities.
“Stovain presents considerable advantage over cocain; it is two
times less toxic, and a safe dose is placed at 3o cg. of a 1:200 solution,
but this dose was exceeded several times, reaching as high as 37 cg.
without observing any trouble. Precautions are notably less im-
portant than with cocain. -
“The irritant action following its use and its weaker anesthetic
power can be largely overcome by using it in normal salt solution and
in slightly greater strength.
“Tropococain. Little clinical experience was had with this alkaloid,
but it appears to be a good anesthetic. Judging from the experi-
mental results, its toxicity and anesthetic value are very close to that
obtained with stovain-cocain.
“Novocain. This appears at the present time the most com-
mendable of local anesthetics; its feeble toxicity permits large doses
to be used without inconvenience; it has considerable anesthetic
power, is non-irritant, and not a vasodilator. The only inconvenience
is that its action is comparatively a little shorter than cocain, but this
can be overcome by the addition of adrenalin, which produces a
prolonged anesthesia of slightly more marked degree without in-
creasing its toxicity. The solution that has given the best results is
the following, recommended by Reclus:
LOCAL ANESTHETICS IO5
Normal Salt solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOO C.C.
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5O C9.
Adrenalin (I: Iooo solution). . . . . . . . . . . . . . . . . . . . . . . 25 drops.”
The above most interesting report, which covers almost the entire
range of local anesthetics as employed to-day, will bear the careful
study of those interested in working out any problems in connec-
tion with the action of local anesthetics.
Some interesting points worth noting are the increased toxicity
shown when novocain was administered intravenously with adre-
nalin. The value of this observation is lessened, as other agents were
not similarly used for a comparative study, and leaves us to draw the
only likely conclusion that the increased toxicity was due to the
action of the adrenalin per se, and not to the fact that it was in com-
bination with novocain.
Another interesting point is that beta-eucain is given a toxicity
equal to cocain; that is, however, entirely against all clinical experience,
which has seemed to show that it possessed a much lower toxicity.
Their observations regarding the irritant action and toxicity of
alypin are decidedly at variance with the German school, but in this
respect our own clinical observations are more nearly in line with
the above.
After a consideration of the above it is seen that novocain pos-
sesses advantages unequaled by any other local anesthetic, being
absolutely non-irritant and six to seven times less toxic than cocain,
and, when in combination with adrenalin, producing an anesthesia
that for intensity and duration equals that obtained by any other
agent, claims sufficient to give it first place in all surgical considera-
tions, which, combined with the fact that it forms stable solutions
capable of repeated boilings without deterioration, make it, at least
for the present time, the ideal local anesthetic.
The above subject was similarly, though less thoroughly, studied
by the Therapeutic Committee of the British Medical Association,
who arrived at nearly similar conclusions, and as a result of their
Studies, have fixed the following scale of toxicity, taking cocain as
the standard of comparison and having it represent I:
Alypin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I.25
Cocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I.OO
Nirvanin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.7I4
Stovain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.625
Tropococain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.5oo
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.490
Beta-eucain lactate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.4I4
Iof LOCAL ANESTHESIA
ANESTHETIC PROPERTIES OF QUININ SALTS
To Dr. Henry Thibault, of Scott, Arkansas, is due the credit of
having discovered the anesthetic properties of this drug. Prior to
Dr. Thibault's discovery and announcement the only record of the
sedative action of quinin is a report by Dr. Fulton, who used it as a
local application to the nose in hay fever (“Jour. Amer. Med. As-
Soc.,” July 20, 1904). -
It is interesting to note that though the hydrochlorid of quinin
and urea, which was first discovered by Driguine in 1881, and ex-
tensively used all over the world as the most soluble salt of quinin
and the best adapted to hypodermic use in the malarial infections,
was not recognized as a local anesthetic until 1907, when Dr. Thibault
first called attention to this property, which it possesses in common
with other salts of quinin, notably the bisulphate. In this the analogy
of historic experience is not unlike that of cocain.
Dr. Thibault informs me that he discovered the anesthetic proper-
ties of the agent while administering it hypodermically to himself
for malaria in June, 1905, by taking a Second injection six hours
after the first in the same place. His experiments and surgical use of
it quickly followed, which he reported in the “Journal of the Arkansas
Medical Society,” September 15, 1907.
We know that quinin is an antiseptic, antiperiodic, antiphlogistic,
antimiasmatic, a diminisher of reflex action, a proplasmic poison,
emmenagogue, and Oxytoxic; we have now to add its anesthetic prop-
erties and swell the list of its already many uses.
‘I used it in an experimental study several years ago in 33 cases,
which included inguinal hernia, varicocele, circumcision, hemor-
rhoids, anal fissure, fistula in ano, Superficial abscesses, ulcers of leg,
epithelioma of face, galactocele of breast, and removal of sebaceous
cysts—a fair range of cases and sufficient to arrive at some conclu-
sions regarding its merits as a local anesthetic. I will give the report
of my observations made at that time.
The first case of any consequence was a large perirectal abscess
and fistula in ano, with multiple perirectal sinuses. It was a trying
case for any form of local anesthesia, and was intended to put the
method to a decided test and develop certain technical details which
I had found necessary from my experience in the office.
The patient, Burnell, aged sixty-seven, was operated from Ward 69, Delgado Memorial,
December 2, 1909. No preliminary morphin or sedatives were used. A 1 per cent. aque-
ous solution of quinin and urea hydrochlorid was selected. The injection was com-
LOCAL ANESTHETICS Io'7
menced in healthy tissue and advanced toward the inflamed area. The initial injection
caused some burning and pain, which lasted about five minutes. By advancing slowly
into the surrounding parts practically no discomfort was caused, no more than was to be
expected from the manipulation of the yet unanesthetized parts. If the infiltration was
advanced too rapidly it produced a return of the burning pain in the freshly invaded
area, but when slowly done this did not occur. Also, if the needle was entered too near
the margin of the infiltrated area, without waiting for anesthesia to be established, it
caused pain, but if a long needle was used and entered some distance back in the anes-
thetized area and advanced gradually by distending the tissues, no pain was produced.
The infiltration process lasted fifteen minutes, and by the time it was complete the area
first injected showed profound anesthesia; those last injected showed sensation to both
touch and pain.
But by operating in the order of the infiltration, by the time the area last infiltrated
was reached, anesthesia was well established. The infiltration was about as thorough as
would have been obtained with any other local anesthetic. Several injections were made
deep into the tissues behind and to the side of the anus to meet the branches of the pudic
nerve as they came down from the spine of the ischium. In all, 4 ounces of a I per cent.
solution was used, 19.2 gr. of quinin salt. The anesthesia produced was everywhere pro-
found. The anus was dilated, the sinuses slit up freely and curetted, and pieces of tissue
removed.
There was no apparent effect on the circulation in situ; there was considerable bleed-
ing and hemostats and ligatures were used. The wound was finally well cleaned and
packed freely.
At no time did the patient suffer any discomfort beyond the burning pain following
the first injection.
At the completion of the operation no infiltration of the tissues was apparent; they
presented the same appearance as would have been expected after a general anesthetic.
No peripheral zone of hyperesthesia could be detected.
After his return to the ward observations were made at intervals during the afternoon
for return of sensibility, and he was instructed to note the time at which he noticed any
painful sensations in the wound. He reported next day that there had been no painful
Sensations, but a feeling of deadness about the operated parts. The only after-effect,
either local or general, was a slight ringing in the ears for several hours.
The wound was then examined and the pack removed. Infiltration of the tissues was
now very apparent. They looked and felt much thickened and presented a pale, edemic,
greyish appearance. Two striking points were noticed. The removal of the pack caused
no pain and was followed by very little oozing of blood. This was in marked contrast
to what would have been expected in removing a pack within twenty-four hours from a
wound of this kind. The wound was dressed daily for the purpose of making observa-
tions, and very little change noticed from day to day. About the third day the tissues
in the wound became sensitive to the prick of an instrument or the grasp of a dressing-for-
ceps, but up to the sixth day the removal of the pack caused no pain. The tissues were
slow in losing the pale, edemic appearance, and some infiltration was still noticed eight days
afterward. The progress of healing seemed much retarded.
Three weeks later, when the patient left the ward, there was still quite a wound, which
he was instructed to care for. He returned at intervals for observation and it was about
six weeks before healing was complete.
Through the kindness of Dr. Matas, I was permitted to oper-
ate, December 7, 1909, on a galactocele of the breast of sixteen
years’ duration in Mrs. M., aged thirty-eight, Ward 7o, Dengado
Memorial. *
Io8 LOCAL ANESTHESIA
The operation was performed in the general amphitheater, and as the patient was
quite nervous, a preliminary injection of morphin, # gr., and scopolamin, Tºw gr., Was
given a short time before; I per cent. Quinin and urea in sterile water was used.
The first injection caused some little burning pain. The tissues around the cyst and
at the base of the gland were well infiltrated. A large incision at the base of the gland,
under its dependent portion, was then made and the breast turned up; bleeding was very
free; the cyst was dissected out and its ramifications entirely removed. Aside from a
little nervousness on the part of the patient, she made no complaint and the procedure was
satisfactory.
Six ounces of the solution was used, 28.8 gr. of the quinin salt. The wound healed
by first intention without much apparent infiltration and in about the usual time.
On January 3 I attempted to operate on an old ulcer of the leg, the result of a com-
pound fracture. It was my intention to curet the base of the ulcer, liberate its edges, and
draw them together.
The patient, Mr. B., aged fifty-three, a railroad conductor. A 1 per cent quinin and
urea solution was used. Infiltration was very difficult, as the tissues everywhere were
much thickened and bound down to the underlying bones. After much effort at infiltra-
tion, in which about 3 ounces of the solution was used and a delay of twenty minutes for
anesthesia to become established, it was finally abandoned, as the tissues seemed as sen-
sitive as at first. Cocain was then used, anesthesia secured, and the operation performed.
Inguinal hernia: Davis, aged thirty-three, Ward 69. Left oblique inguinal hernia,
duration, four years; operation, January 14, 1910, 1 per cent. Quinin and urea.
No complaint was made at any time by the patient and anesthesia was very satis-
factory; 7 ounces of solution were used, as the hernia was very large. By the time the
superficial injection of the skin was completed anesthesia was established. The field was
very vascular. No hyperesthesia was noted and no induration was seen at the completion
of the operation. The dressings were not disturbed for one week, as the wound had
remained perfectly comfortable and the patient had no temperature.
When the dressings were changed the wound presented a brawny induration, ex-
tending over the entire area of infiltration; the tissues were much thickened and felt
leathery. A few superficial stitches were loosened without any pain and fresh dressings
applied. These were changed in two days. Some serous exudate was found. The wound
remained much the same in appearance. About the tenth day suppuration became more
apparent, and finally extended down to the aponeurosis of the external oblique, a portion
of which sloughed away. Healing was very slow. The patient remained in the ward over
one month and became restless and left before healing was complete. I do not know what
effect the infection will have upon the final result. I asked the patient to return for later
observation, but he did not do so.
Epithelioma of right cheek: Mr. C., aged fifty-one, carpenter. Growth was as large
as a quarter and had existed for three years. Operation in office, January 5, 191o;
# of 1 per cent. quinin and urea was attempted, but proved insufficient after fifteen
minutes’ delay. The strength was gradually increased until 1 per cent. was used, which
produced profound anesthesia. The growth was removed by a wide incision and good
approximation of the wound secured with silk sutures. A suitable dressing was applied
and changed in two days, when much induration of the wound was noticed. Infection
became apparent by the fifth day. The wound was three weeks in healing and left quite
a SCallſ.
Many other minor operations were performed before and since
these detailed cases, including circumcisions, hemorrhoids, rectal
fissures, fistulas, varicocele, buboes, etc., most of which were done in
the office. From o.25 to I per cent. in sterile water or salt solution
LOCAL ANESTHETICS Io9
was used. The weaker Solutions proved effective in loose cellular
tissues, like the scrotum or skin of the penis, and their use was always
followed by less induration and less danger of slough than the stronger
solutions. I did not find that the addition of normal salt solution in-
fluenced the results to any marked extent. About the rectum the
I per cent. Solution was always found necessary, and succeeded well
in all but one case, when it was abandoned and cocain used.
The after-effects, when used about the rectum, are in marked
contrast to that following the use of cocain solution. When the quinin
solution was used in the removal of hemorrhoids, practically no after-
discomfort was complained of, the anesthesia lasting until healing was
well under way, while similar operations performed with a cocain
Solution are always followed by much burning and pain after the anes-
thesia dies out. Particularly about this region is a preliminary in-
jection of a Syringe full of Schleich solution, to prevent the burning
Sensation following the first injection of the quinin solution, advisable.
As Some infection always follows operations on these parts, I have not
found that the quinin solution added to the suppuration sufficiently
to be objectionable, but judgment must be used in selecting the
Operation for its use or embarrassing results may follow.
I would not care to undertake a resection of the bowel or extensive
Whitehead operation with quinin as the anesthetic, but if a local
anesthetic was to be used would much prefer a novocain solution.
In circumcisions the o.25 per cent. Solution has some points to
Commend it. The pain and discomfort associated with the trying
erections which follow this operation are absent when quinin is used
and no discomfort is experienced when changing the dressings.
In seven circumcisions, performed in this way, I have had fairly
good results, and much time and annoyance was saved myself and
the patient, and I have not found that healing was interfered with
to any great extent. The wound was generally well in about ten
days.
However, I noticed in several of the cases that the infiltrated skin
often had a dark ecchymotic appearance afterward, which, at times,
took on a threatening aspect. I have accordingly discontinued its
use in these parts for fear of possible serious consequences.
I have used it in the bladder in 15 and 20 per cent. solutions, but
did not obtain very satisfactory results. Used topically in the rectum
in the above strengths it has given fair results. A very thorough
study of its action and surgical uses was undertaken by Drs. Hertzler,
Brewster, and Rogers, and reported in the “Journal of the American
I IO LOCAL ANESTHESIA
Medical Association,” October 23, 1909. I quote the following from
their report:
“Hertzler undertook to determine experimentally the cause of
the induration. Experiments performed on rabbits showed that the
thickening was not due to cellular infiltration at all, as was supposed
on clinical grounds, but was due to a pure fibrinous exudate free from
cells. This exudate was proved to be fibrin by Mallory's and Weig-
ert’s stain. The reaction appears, therefore, to be purely chemical in
nature. The exudation of the fibrin begins to appear within a few
minutes. In a general way it determined the amount of exudate de-
pending on the strength of the solution used; the attempt was made,
therefore, to determine a strength of solution which would not cause
this exudation of fibrin. In o.5 per cent. Solutions the exudate is
less than with I per cent., and with only o.25 per cent. Solutions only
traces can be discovered. To what extent this fibrinous exudate is
subsequently converted into fibrous tissue has not yet been definitely
determined, but apparently nearly all is absorbed.
“In order to determine the subjective sensations of the injection,
and to determine the question of a possible zone of hyperesthesia
about the anesthetized zone, one of us (Hertzler) studied the effect
by the injections in the skin of his leg. Injections of I, o.5, o.25, and
o.167 per cent. Solutions and an injection of plain water as controls
were used in each series. The I and o.5 per cent. Solutions gave im-
mediate and complete anesthesia without a particle of pain during
its introduction. Within a few minutes there was a distinct induration.
With the o.25 per cent. Solution, anesthesia was not complete for a
few minutes, but was then as complete as after the use of the stronger
solutions. The o.167 per cent. Solution gave delayed anesthesia, but
after a few minutes was complete. In neither of these weaker solu-
tions was induration noted on palpation. The water-control caused
intense pain on injection, and the anesthesia, at no time perfect,
lasted but a few minutes. There was a zone of hyperesthesia, I or
2 inches in width, about the area injected. Curiously enough the
hyperesthesia seemed to be for touch and not for pain.
“The duration of the anesthesia in the I and o.5 per cent. Solutions
was perfect for four or five days, and sensation in the o.5 per cent.
strength was not restored to any great extent for ten days, and in
the I per cent. solution sensation was not completely restored after
two weeks. At no time was there the least pain, though the indura-
tion about the I and o.5 per cent. Solutions was yet marked at one
and two weeks, respectively.
LOCAL ANESTHETICS III
“The above observations were made with the solution of the
quinin in water. When physiologic salt solution was used as the
solvent, the induration was little or not at all marked, but the
duration of the anesthesia was much lessened. Hypotonic and
hypertonic solutions also were used without notable variation.
“The result of this experimentation indicated that the delayed
skin union above noted was due to fibrinous exudate. This was pres-
ent in the I and o.5 per cent. Solutions, but not in the o.25 per cent.
Solution to any notable degree. The o.25 per cent. solution seemed,
then, on laboratory grounds, to be the strength most desirable for
anesthesia in the class of work where speedy primary union of the
skin is desirable, and where duration of anesthesia beyond several
hours is not required, and clinical experience seems to bear out the
laboratory determinations.
“Any operations ordinarily done with cocain can be done with
quinin. The technic of its use is the same. As in the use of cocain,
only those tissues known to be sensitive should be injected. In clean
tissue the o.25 per cent. Solution seems to be strong enough to pro-
duce anesthesia, lasting several hours. In regions where primary
union is not necessary, particularly in tissue, the seat of inflammatory
reaction, the stronger solutions are more satisfactory. In the open-
ing of the abscesses, for instance, and operations for anal fistulas,
hemorrhoids, etc., the stronger solutions are the ones of choice. In
regions where the operation is attended by hemorrhage, too, notably
tonsillectomy, tubinectomy, etc., the I per cent. solution or stronger
(3 per cent., Brown) is the solution of choice. The stronger Solution
is desired here because of the hemostatic effect exercised by the
fibrinous exudate. The exudate being fibrin in the strict chemical
sense, the usual natural processes of hemostasis are anticipated. The
coagulum occurs, it is true, about and not in the vessels, and their
occlusion, therefore, results from the pressure from without. The im-
portant point, however, is that the effect lasts from seven to fourteen
days, a time abundantly sufficient to allow healing by granulation
to become well advanced. This is in marked contrast to the ephemeral
influence of cocain and adrenalin, which act only by causing a Con-
traction of the muscular walls of the blood-vessels.
“We have done the following operations, among others, under
quinin anesthesia: Drainage of the gall-bladder, drainage of appendi-
ceal abscesses, exploratory laparotomies, hernias, castrations, varico-
cele and hydrocele operations, etc., and the removal of all sorts of
tumors ordinarily undertaken under cocain.
II 2 LOCAL ANESTHESIA
“We desire particularly to emphasize the value of this anesthetic
in two operations. In operations about the anus it is for us the anes-
thetic of choice. In both fistulas and hemorrhoids any of the radical
operations can be performed with the same thoroughness as under a
general anesthetic. The advantage consists in that the duration of
the anesthetic is from seven to ten days, which does away entirely
with the after-pain ordinarily attending these operations. In ton-
sillectomy the results have been equally satisfactory. For this opera-
tion a large amount of the solution is injected about the tonsil, be-
tween it and the faucial pillars. This forms an artificial edema about
the tonsil which much facilitates its removal. An unlimited amount
of solution may be used with impunity, so that a satisfactory anes-
thesia can be easily secured. Because of its safety, both tonsils may
be operated on at one sitting. The absence of after-pain is as desir-
able here as following an operation about the anus.
“As a local application about the eye we have no experience, but
turbinectomies and septal spur operations have been done with a fair
degree of satisfaction when the drug was used as a topical application.
For local application the strength must be from Io to 20 per cent., as
correctly stated by Thibault. When the solution is injected beneath
the mucosa, however, anesthesia is perfect and hemorrhage slight.
“In the bladder, as a preliminary to cystoscopy, the result has
been very satisfactory. A solution of from Io to 20 per cent. is used
and allowed to remain from twenty to thirty minutes. The only
objection to this solution is the difficulty of removing the precipitated
flocculi from the bladder after the anesthesia is complete. These
flocculi work no further mischief than to obscure the vision.”
Quinin and urea hydrochlorid has been recommended in the
treatment of neuralgia. We have had but a limited experience with
it in this field, and that has not been satisfactory. The following is
from a recent article by Dr. Matas:
“I have had occasion to try both the bichlorid of urea and quinin
and the bisulphat in the treatment of trigeminal neuralgia, and as a
preliminary to the extirpation of the second and third divisions of
the trigeminus, associated with the alcohol injections into these
nerves at their exit from the base of the skull (Schlosser's method).
My experience has brought out most forcibly the objections above
stated:
“In the case of an aged gentleman, Judge H., aged seventy-three years, who consulted
me two months ago for a most violent tic douloureux of the infra-orbital and inferior
maxillary divisions of the trigeminus, I felt especially anxious to avoid any extensive
LOCAL ANESTHETICS II3
operation which might require a general anesthetic, because he was a corpulent man with
a dilated heart, chronic asthma, and emphysematous lung. I decided in this case to try,
as on many previous occasions, the effect of a deep, massive infiltration of the nerve-
trunks at the base of the skull, and thus obtain a regional anesthesia, as a preliminary
to the excision of the nerves after injection of the nerve-trunks with alcohol. I used a
solution of quinin bisulphate (I percent.) with adrenalin solution (I: Iooo) , 20 minims of the
adrenalin to 5 ounces of quinin solution. With my special infiltration apparatus I edemat-
ized the Sphenomaxillary and zygomatic fossae by introducing the needle of the pump into
these regions through the sigmoid notch of the lower jaw. The anesthetic effect on the
peripheral distribution of the nerves was pronounced in half an hour, but in a few hours
I was much worried by the persistence of the edematous swelling of the entire cheek and
face on the corresponding side and extreme induration of the infiltrated parts. The
paroxysms of pain, which subsided for a day, gradually returned to their original violence,
the hard swelling of the cheek persisting for nearly two weeks. I then decided to reinject
the nerves with my regular beta-eucain (o.2 per cent.) and adrenalin solution. With this
infiltration the anesthesia was so complete that I was able to resect both nerves painlessly.
The inferior maxillary was exposed above the origin of the inferior dental by deepening the
sigmoid notch and following the nerves toward the foramen ovale (Victor Horsley's
method). The infra-orbital nerve was exposed and followed through the orbit to the
Sphenopalatine fossa by a simplified Carnochan method. Both nerve-trunks were in-
jected interstitially with alcohol as near the point of exit as possible from the skull, and
then torn away by twisting with forceps, the peripheral distribution being extracted by
Thiersch's method. The relief obtained by this procedure was complete and satisfactory.
“In this case I learned, first, that the anesthetic effect of the quinin
Solution was not as pronounced as when beta-eucain was used; and,
Second, that the long-lasting hard Swelling after the quinin, even
when used in combination with adrenalin, was not a negligible after-
effect.”
The intra-abdominal use of the drug was tried by Dr. Thibault, and
reported in the “Journal of the American Medical Association” in the
article which I quote below. In view of the non-toxicity of the drug,
and the consequent freedom with which it can be used, its action
here should be borne in mind, as it may prove of advantage under
certain conditions.
The following report of an experience with the bimuriate of quinin
and urea hydrochlorid may prove of some value to surgeons doing
abdominal work, especially in cases in which general anesthesia is
undesirable:
“History.—Strangulation of an old inguinal hernia occurred March Io, in a negress
aged sixty-four, who had, in addition, inoperable cancer of the uterus and rectum. The
circulation was poor. There were arrythmia, edema, considerable arterial sclerosis, begin-
ning dilatation of the heart; slight cough, some preliminary secretion, and a parenchy-
matous nephritis.
“Operation.—Immediate operation was necessary, and both physicians called in con-
Sultation thought that general anesthesia would almost certainly prove fatal. The opera-
tion was done under local anesthesia, induced by injecting o.25 per cent. solution of quinin
8
II4 LOCAL ANESTHESIA
and urea hydrochlorid. The tissues above the canal were moderately infiltrated with the
solution and there was no pain until after the canal was laid open, when the peritoneum
was found to be quite sensitive. About 2 drams of the warmed solution was poured into
the canal and in a few minutes there was perfect anesthesia of the parietal peritoneum
and the operation was finished without the patient at any subsequent time feeling any
pain, although considerable adhesions were broken up. There was no local reaction in
the peritoneum, union was primary, and there was no shock. The fluid poured into the
canal gradually escaped into the abdomen as the adhesions were broken up. There was no
pain after the operation and nothing to indicate that any peritoneal irritation had taken
place.
“While it is dangerous to draw conclusions from a single case,
this report is at least worth attention, and suggests that the solu-
tion might be poured into the abdomen and more extensive opera-
tions done without pain or injury to the patient, as the presence of
the solution seems to render the handling of the abdominal viscera
painless.”
Judging quinin by the standard set for any new local anesthetic,
and comparing the many claims made for it with our clinical expe-
rience, we find that (1) compared with cocain, novocain, and beta-
eucain, its local anesthetic effect is not as rapidly obtained.
This is especially true of its topical application to mucous mem-
branes. On the other hand, when the anesthesia is obtained, it is of
very much longer duration, the after-pain in Some operations being
thus avoided, a great advantage in nasal and rectal work when pain-
ful dressings must be removed shortly after the operation. (2) The
local anesthetic effect is not only slower in its appearance, five to
fifteen minutes, but is less diffused. It spreads over a more restricted
area than with cocain and other local anesthetics. (3) Quinin acts
as a vasodilator and favors capillary oozing. (4) It produces a sec-
ondary indurative reaction in the tissues, due to a fibrinous exudate,
which appears a few minutes after injection and in a general way is
dependent upon the concentration of the solution.
While from the point of view of repair this excess of fibrinous reac-
tion is a disadvantage, since it tends to interfere with the healing of
wounds, it is also an advantage in producing a secondary and per-
manent hemostatic effect by producing a perivascular compression,
which may be utilized profitably in some operations associated with
much secondary oozing. This may be the case in rhinologic work and
in hemorrhoidal operations, where, in addition to long anesthesia,
a permanent hemostasis is desirable.
The primary vasodilator effect and interference with healing,
with long persistence of hard swelling when the more effective quinin
LOCAL ANESTHETICS II.5.
solutions are used, is a serious drawback in aseptic operations where
quick primary healing is desirable, and will militate against the
general acceptance of quinin as a routine anesthetic, its non-toxicity
notwithstanding. It is possible that by combining the quinin and
urea hydrochlorid with adrenalin solution the objectionable oozing
due to the primary vasodilator effect may be overcome; but it would
appear that by this combination the vasoconstrictor effect of the
adrenalin is diminished and the ischemia is not obtained, as is the
case when some of the cocain substitutes are combined with adrenalin
(Gaudier). Neither does this combination appear to have a very
marked influence in diminishing the objectionable fibrinous exuda-
tion of quinin in my experience.
The practice of combining two or more drugs in solutions weaker
than any one could have been effectively used alone has lately met
with much favor, thereby often retaining the good points of each
while being able to eliminate objectionable effects. Schleich, in this
way, has combined alypin with cocain in the formulae for his solutions
which he recommends at present. It may be possible to combine
quinin in this way, thereby retaining some of its desirable qualities.
In conclusion, it is only fair to state that whatever may be the
objections to the routine use of the quinin as a local anesthetic in
surgical practice, we must admit that there is always place for a
reliable anesthetic as quinin has proved to be, which is absolutely
free from toxicity. (Brewer has injected Ioo gr. of the bichlorid
of urea and quinin intravenously in the course of six hours in a case
of pernicious malarial infection without ill effects.)
This non-toxicity, coupled with the extraordinary duration of the
anesthesia (one to six days), will always keep this remarkable drug
in the mind of every surgeon who is constantly facing the problem of
local anesthesia in its multitudinous phases in the daily routine of
surgical practice. Furthermore, in view of the remarkable proper-
ties which quinin possesses, as above stated, it is to be hoped that
every effort will be made to overcome the objections which we have
previously noticed by combining its salts with other agents that will
modify or neutralize its undesirable reaction in the tissues.
In discovering this unknown and most valuable property in a
long-familiar drug, Dr. Thibault has contributed a valuable addition
to the surgeon's resources in annulling pain and has proved himself
an unusually keen and perspicuous observer.
While the study of the local action of this drug is highly interesting,
we do not féel, in the present stage of its development, that we can
II6 LOCAL ANESTHESIA
recommend its use for any but a limited number of rectal operations;
possibly the surgeon specialist may select it for certain nose and
throat work. -
An interesting point upon which we have been unable to secure
any information is its surgical use as an anesthetic in those said to
possess an idiosyncrasy to the drug. In the large number of cases
already reported no such observations have been made.
While this book is going through the press there appears in the
literature an article by Dr. F. W. Parham, on Quinin and Tetanus
(“New Orleans Med. and Surg. Jour.,” October, 1913), in which this
valuable drug is incriminated as an exciting cause of tetanus. This
arraignment is so convincing that I record it here as a caution against
its unguarded use, particularly as there appears the tendency to ex-
tend the field of usefulness of quinin as an anesthetic. At least One
fatal case of this dread disease has occurred recently in New
Orleans in which quinin seemed to have been the exciting cause.
In all cases so far in which tetanus has followed the quinin was
in concentrated solution, and usually administered for malaria, but
as the determining factor seems to have been the area of necrosis
which the injection produced this would seem possible in the solutions
ordinarily used for purposes of anesthesia, o.25 to I per cent., which
at times has been found to produce necrosis, as in some of the cases
reported in the preceding pages. As this mere statement of facts may
fail of its purpose without the production of further proof or argu-
ment, I copy the following taken from Dr. Parham’s article, which is
a quotation from Major S. P. James, January, 1911, number of
Paludism, in which he summarizes the work of Sir David Semple on
this subject:
“Cases of tetanus sometimes occur after the hypodermic or intra-
muscular administration of quinin, and it may now be regarded as
proved that such cases are not always due to a contaminated needle
or solution, but sometimes occur in circumstances in which the ster-
ility of the apparatus used, of the fluid injected, and of the patient's
skin at the site of injection is assured. The results of the present
investigation indicate the probable cause of such cases, the danger
attending the hypodermic or intramuscular administration of quinin,
and the procedure by which that danger may be avoided.
“The author's explanation of the occurrence of tetanus when no
tetanus spores have been injected with the quinin solution rests upon
the following findings: (1) Many people in good health harbor tetanus
spores in their bodies, either in healed wounds or in the intestinal
LOCAL ANESTHETICS II 7
Canal. Hidden away in the tissues the spores remain alive and retain
their virulence, but, for one reason or another, they do not grow into
toxin-producing bacilli. It appears that such tetanus-spore carriers
may be quite common, for, as regards the intestinal canal carrier,
Colonel Semple found the spores in the feces of four out of every ten
persons examined. The frequency of ‘healed-wound carriers’ is not
known, but probably is considerable, for it is reasonable to suppose
that the majority of people have suffered slight injuries accompanied
by the introduction of tetanus spores, but not followed by tetanus,
and that at least Some of these people harbor in the healed tissues a
few spores which have not been destroyed by the phagocytes, and
which, from the absence of anerobic conditions, or from some other
Cause, do not grow into toxin-producing bacilli. In the thirteenth
Series of experiments described by Colonel Semple, eight guinea-pigs
were inoculated in the hind leg with spores entirely free from toxin
(‘washed tetanus spores'). The animals remained healthy. At periods
varying from five weeks to seven months after inoculation the guinea-
pigs were killed, and Small pieces of the subcutaneous tissue at the
site of inoculation were removed aseptically, placed in tubes of broth,
and incubated. In all the eight experiments true tetanus bacilli,
which were found to be virulent, were recovered. These results
prove that living tetanus spores can remain in the tissues for at heast
seven months without being destroyed by the phagocytes and without
causing tetanus; and it is reasonable to suppose that a similar condi-
tion obtains in persons who have suffered an injury accompanied by
the introduction of tetanus spores, but not followed by tetanus; most
of the spores are followed by phagocytosis, but some of them escape
and become hidden away in the tissues, where they remain for months
or years after the wound has healed. (2) The second finding is that
these tetanus-spore carriers are in danger of suffering from tetanus: (a)
on the occurrence of circumstances (such as great fatigue or exposure
to extremes of heat and cold) which lower their normal power of keep-
ing at bay the germs which they harbor; (b) when the site where the
spores are lodged becomes converted into a medium which, from being
anerobic and from a failure of phagocytosis, is favorable for the growth
of the spores into toxin-producing bacilli; (c) when a focus of dead
tissues forms in a part of the body at a distance from the site where the
Spores are lodged.
“For our present purposes the third of these conditions is the most
important, and in regard to it Colonel Semple has proved, especially
by his series of experiments numbered III, VII, XVI, and XVII,
II8 LOCAL ANESTHESIA
that the ‘latent’ or ‘dormant’ tetanus spores are sometimes conveyed
from the site where they were harmless to a site (such as that of a
quinin injection) where they can develop abundantly and produce
sufficient toxin to cause tetanus. (3) The third finding is that the
results of injecting quinin hypodermically or intramuscularly are, (a)
local destruction of tissue, and in most cases the formation of a slough
which includes the true skin, the Subcutaneous tissue, and the deep
fasciae; this means the formation of a subcutaneous necrotic area
which is an anerobic medium very favorable to the growth of tetanus
spores; (b) the paralysis of the leukocytes so that their phagocytic
action is hindered.
“If we have interpreted Colonel Semple's paper rightly, the ex-
planation of the occurrence of tetanus after an uncontaminated and
aseptic hypodermic or intramuscular injection of quinin, is, on the
basis of the above findings, not difficult. Suppose the malaria patient
to be a tetanus-spore carrier, the spores being situated in the intes-
tinal canal, and suppose we inject the quinin solution into the patient’s
buttock, and by so doing produce there a local subcutaneous patch
of dead tissue, leukocytes from all parts will crowd to the injected
area, and it may happen that some of them contain tetanus spores
gathered from the alimentary canal as a result of an abrasion of the
mucous membrane. The spores that have been conveyed to the
necrotic patch will find the conditions there very suitable for develop-
ment into toxin-producing bacilli, and tetanus will ensue. Similar
events might happen if the tetanus-spore carrier was a person in
whom the ‘latent’ or ‘dormant’ spores were situated in the site of an
old wound on any part of the body.
“If we accept this explanation, it is easy to understand why, even
in tetanus-spore carriers, injections of non-irritating drugs, such as
morphin, cocain or digitalin, are not followed by tetanus. These
solutions are quickly absorbed and no local destruction of tissue re-
sults, so that the person remains free from a focus suitable for the
germination and growth of the spores; and as regards those drugs,
even if tetanus spores were injected along with the solution, it is
probable that, the activity of the leukocytes being unimpaired, all
the spores would be destroyed at the site of the injection.
“From this brief sketch it will be clear that there is considerable
danger in administering quinin hypodermically or intramuscularly,
even with the strictest aseptic care. For this reason it is fortunate
that Colonel Semple has been able to prove, by his nineteenth series
of experiments, that tetanus antitoxin is a trustworthy prophylactic
LOCAL ANESTHETICS II9
against tetanus when it is necessary to administer quinin by those
methods. When the drug has to be administered hypodermically or
intramuscularly, an injection of antitetanic serum should be given
immediately before, or immediately after, the quinin injection.
Colonel Semple recommends an injection of Io to 15 c.c. of the serum
into the loose subcutaneous tissues of the side of the abdomen, and
states that this amount would confer upon the patient a passive im-
munity to tetanus for two or three weeks. If this procedure is adopted,
the hypodermic and intramuscular administration of quinin can, so
far as the danger of tetanus is concerned, be carried out with safety.”
ANESTHETIC PROPERTIES OF MAGNESIUM SALTS
The anesthetic properties of magnesium salts were discovered
through the experiments of Dr. S. J. Meltzer, of New York. He had
reasoned that the phenomena of life results from the interaction of
excitation and inhibition. There are four principal inorganic con-
stituents of the body—Sodium, potassium, calcium, and magnesium.
Of these, the first three have been shown to possess a stimulatory
effect on muscle and nerve. It, therefore, remained for magnesium
to exert an antagonistic or inhibitory effect. The theory was ac-
cordingly put to test. The application of magnesium sulphate to
nerve-trunks was found to block conductivity and abolish excita-
bility. The intracerebral injection of magnesium sulphate was next
tried, and found to induce a state of general inhibition; subcutaneouly,
it produced deep narcosis and complete muscular relaxation; intra-
venously, it produced the same effect, also arresting intestinal peris-
talsis. Both the subcutaneous and intravenous injections produced
Complete muscular relaxation in tetanus, lasting often as long as
twenty-four hours. These experiments were tested by many and
found to be correct, but when locally applied to an open wound it
did not seem to exert any sedative action.
Guthrie and Ryan, in testing the action of magnesium salts,
came to the conclusion that they produce a general muscular paralysis,
and in this state the animals were unable to respond to sensory stimu-
lation, and when general anesthesia was produced it was due to the
paralysis extending to the respiratory muscles, and the degree of
anesthesia depended upon the degree of asphyxiation.
This contention was later disproved by Meltzer, and as con-
firmed by the intraspinal injection of magnesium sulphate on human
Subjects who were operated upon in a thoroughly conscious state
with undisturbed respiration, but completely anesthetic below the
I2O LOCAL ANESTHESIA
point of injection. It leaves no doubt regarding the anesthetic prop-
erties of magnesium sulphate.
(For the intraspinal injection, see section on this subject.)
The intracerebral injection of magnesium chlorid has been tried
on laboratory animals and found to produce complete muscular and
sensory paralysis, and has been suggested as a means of anesthesia
for laboratory use. -
Notwithstanding the undoubted paralyzing effects of magnesium
salts in tetanus, where it has been tried and found to control the
convulsions, its depressing effect was too great and no reduction was
accomplished in the mortality, the high temperature continuing and
the patient dying from exhaustion or as a result of the action of the
toxins of the disease.
Local applications of solutions of magnesium sulphate have been
found to give relief when used for neuralgias, headache, pleurisy,
pericarditis, and various abdominal pains. This sedative action is
by no means constant and often fails, but it is a simple method and
worthy of trial where opiates and other sedatives are to be avoided.
This sedation is not accompanied by any local anesthesia, but seems
to be through reflex action.
CHAPTER VI
TOXICOLOGY
SINCE the introduction of Schleich's infiltration anesthesia, and
the knowledge that effective operative analgesia of the tissues could
be obtained by infiltration and Saturation with solutions even as weak
as I: 20,000, caused an abandonment of the use of the strong solutions
(5, Io, or even 20 per cent.) that were in common use in the early days
of cocain anesthesia, with their tremendous array of fatalities or alarm-
ing symptoms which were reported from every quarter, and served
largely to discredit the use of this agent or limit it to very restricted
fields. At the present time, with the improvement in our methods
and the addition of adrenalin and other aids and the use of solutions
not exceeding o.25 or o.20 per cent. for ordinary filtration, or o.5 to
I per cent. for nerve-blocking (only a few drops being necessary), have
greatly lessened or almost entirely eliminated the toxic action of this
drug in general Surgery to such an extent that men of large expe-
rience in its use have not had a single case of the toxic action of this
drug.
In our own experience we have fortunately not had a case of
poisoning from cocain or its allied drugs to deal with, but have occa-
sionally seen these cases, and they will continue to occur in the hands
of those inexperienced in its use and its dangers who uncautiously
use strong solutions. In the practice of dentists and surgical special-
ists (eye, ear, nose, and throat), who make use of solutions stronger
than those now used by the general Surgeon, cases of poisoning are
frequently occurring.
The solutions used in this line of work are often I per cent. for
infiltration, and for topical application Io, 20, and 30 per cent., or
even stronger, and should be used with great caution, as prevention
is better than cure, applying only small quantities at a time and not
to over-saturate tampons or allow the solution to drop to other parts
or to run from the point of the application to be absorbed elsewhere,
and always safeguarding these applications with adrenalin.
The poisonous effects of cocain and its allied drugs and other
agents used for their local anesthetic action may be either local or
121
I 22 LOCAL ANESTHESIA
constitutional. As illustrations of local irritating action may be
mentioned the inflammation occasionally seen to follow the use of
alypin and stovain in strong Solutions, and the action of stovain on
nerve-tissue, notably in spinal puncture; also the local necrotic action
of quinin and urea, or the local destructive and inflammatory action
of carbolic acid. The prolonged freezing by ethyl chlorid will produce
coagulation with destruction of tissue. All these local effects are dis-
cussed in the chapters with the action of these different agents; here
we propose to discuss the general or constitutional action.
In speaking of this toxic action cocain will be taken as the type,
for what applies to cocain is equally applicable to all of its congeners,
with perhaps very slight or inconsequential differences in Some few
Ca,SeS.
Cocain is recognized as a universal protoplasmic poison effecting
all protoplasm, animal and vegetable alike. When gradually absorbed
in toxic doses, acting first as an excitant, paralysis follows after a
more or less brief period of excitement. When injected into the
circulation in toxic doses the stage of excitement is so short as to escape
observation, paralysis taking place almost immediately.
It must be remembered that the local anesthetic action of cocain
is the result of a local paralysis of the parts affected; all tissues are
similarly effected by its use, nerves of special sense, motor nerves,
muscle-fiber as well as sensory nerves, and white blood-corpuscles
loose their ameboid movements when in contact with its solutions,
and its constitutional or central action is the result of this paralysis
upon the higher nerve-centers.
This paralysis is the result of a definite chemical combination,
and the longer the solution remains in contact with the tissues at
the point of injection the more pronounced becomes this chemical
combination, and consequently the more pronounced the anesthesia
(paralysis).
These facts should guide us in its use: first, to keep within the
limits of safety; secondly, to use means to retain it at the point of
injection or application; and, finally, should toxic symptoms arise,
to apply at once such measures (constriction) if possible as will check or
delay further absorption, as well as such other measures as have been
suggested elsewhere to combat this toxic action.
The soluble salts of cocain are absorbed with great rapidity.
They have the power of passing with great facility through nearly
all mucous membranes, so that their absorption is almost immediate
when topically employed on such surfaces as the nose, throat, mouth,
TOXICOLOGY I23
urethra, eye, and rectum, consequently the greater number of cases
of poisoning have resulted from their use in this way.
The ultimate fate of cocain after absorption into the body is some-
what in doubt; it is believed that when slowly absorbed to be entirely
broken up by the body-cells (Moreno y Maiz); when more rapidly
absorbed very small quantities (5 per cent.) have been recovered
from the urine.
It is believed that cocain once fixed by the body-cells (in combina-
tion with them) is not liberated from these combinations as cocain,
but as constituent products, ecgonin, etc.; Glasenap believes he has
isolated ecgonin from the urine. These derivatives of cocain are
slightly anesthetic and slightly toxic, but much less so than cocain.
As a result of the preceding statements it can be said that cocain
exerts its full anesthetic or toxic action but once, and if exhausted
locally there will be no constitutional reaction.
It can be further stated that that portion of the cocain which is
absorbed and acts upon the general system producing toxic symptoms
is the excess over that fixed by the tissues locally, consequently that
much in excess of the amount needed to thoroughly saturate and com-
bine with the tissue-cells producing in them complete paralysis; in
considering this statement it must, however, be borne in mind that
on very actively absorbing surfaces and in very vascular tissues,
where no aids are used to retard absorption, such as constriction or
adrenalin, that much of the drug is rapidly taken up and transported
by the veins and lymphatics to the central nervous system before
but a very limited quantity of it has had time to be fixed by the tis-
sues and act locally. This and other statements are borne out by
the clinical experiences in the cases of poisoning by comparatively
Small doses in comparison to the amount used under other conditions
without ill effects. Mattison reports a case by Knabe where I2 drops
of a 4 per cent. Solution given hypodermically to a young girl of
eleven years caused death in less than one minute. Garland reports a
death following the application of 20 drops of a 5 per cent. Solution
to the gums. Hundreds of such cases have been reported, and many
cases of idiosyncrasy showing poisonous symptoms from remark-
ably small doses; these, however, have all been in strong solutions, I
per cent. and over, and only serve to emphasize the caution given
that when using such agents to keep well within the safe limits and
use only the weakest dilutions compatible with efficiency; the toxic
action will vary in direct ratio to the strength of the solution and
the rapidity of absorption.
I24 LOCAL ANESTHESLA
Three-quarters of a grain of cocain is given as a safe average
dose, but this varies within wide limits; less than this amount may
produce poisonous symptoms if too rapidly thrown into the circula-
tion in susceptible individuals, while many times this amount can
be given when well diluted, distributed over a large area, and safe-
guarded by measures to retard absorption.
Patients who once have been poisoned by cocain often show a
marked susceptibility to remarkably small doses; this fact should be
borne in mind when dealing with patients who give such a history.
The power of the tissue-cells to combine with and destroy cocain
is not limited to this agent alone, but is true of many other poisons,
animal as well as vegetable; we may mention Strychnin and Snake
venom, particularly in the case of Snake-bité upon an extremity;
all are familiar with the action of a constrictor proximal to the point
of bite, thus retaining in situ the Snake venom, allowing it to exhaust
its force upon the tissues locally which intensifies its local action,
often leading to extensive necrosis but saving the general system.
The same is true of cocain, many times the toxic dose can be
injected into the tissues locally if retained in situ by the use of a con-
strictor or adrenalin, but particularly in this case with a constrictor,
and largely diluted so as to freely diffuse it and bring it into contact
with a larger number of tissue-cells, when if retained sufficiently long
the strength of the drug is exhausted and little or no constitutional
effect will be noted when liberated into the general system; in the case
of excessive doses this should be gradually done by the intermittent
relaxation of the constrictor.
The relative toxic effects of the drug when liberated into the sys-
tem by various routes has frequently been the subject of study by
many investigations.
Petrow found in animal experimentation that the toxic dose was
two to three times greater when using a constrictor, which, however,
was not allowed to remain on very long (time not given), while the
lethal dose was seven to ten times greater than that needed without
a constrictor.
V. Oppel, in experimenting along the same lines, found that the
lethal dose of cocain when injected into the arteries is eight to ten
times greater than the intravenous, while subcutaneous injections are
two to three times less dangerous than the arterial and fifteen to
twenty times less dangerous than intravenous injections. Other ob-
servers, in working along the same lines, have arrived at nearly
similar conclusions.
TOXICOLOGY I25
In considering the above statement, it is readily understood how
the intra-arterial injections are more dangerous than subcutaneous
when it is realized that, even though the solution is being carried
away from the centers, it does not leave the lumen of the vessels, and
the time required for the circuit is comparatively short when meas-
ured by the time necessary for cocain solutions to combine with the
tissues, besides the entire volume is delivered at once into the general
circulation with the returning blood. The subcutaneous injections are
weakened by the action of the tissue-cells outside of the vessels, and
is slowly and gradually taken up to be liberated into the general
circulation slowly over a considerably longer period of time.
The age and condition of the patient is also an active factor in
considering the toxicology of these drugs; childhood and early youth,
due to the highly sensitive and impressionable nervous system, as
well as the influence which psychic impressions may play, are rela-
tively much more susceptible to the toxic influence of these drugs than
are adults; on the other hand, old age, where so often general anes-
thetics may be contra-indicated, is particularly favorable to all local
anesthetic procedures. This question of age is considered more thor-
oughly under Indications and Contra-indications, as well as other
conditions of the patient which may operate for or against the toxic
action of these drugs. While # gr. of cocain is given as the maximum
safe dose that can be absorbed into the circulation at any one time,
still this dose may be many times exceeded with perfect safety when
largely diluted, diffused over a large area, and slowly absorbed; the
danger of toxicity depends entirely upon the strength of the solution
and rapidity of absorption; we have repeatedly used, 8, Io, or 12 ounces
of Schleich's solution No. 1, containing o.96 gr. of cocain to the
ounce, or our solution No. 1, containing 1.2 gr. of novocain to the
ounce, when performing very large and extensive operations under
infiltration anesthesia, without once ever having seen any toxic ef-
fects; 32 ounces of Solution No. 1, containing 38.4 gr. of novocain, was
used in doing an extensive lipectomy without any disturbance. Of
course, in these procedures some of the solution escapes from the
tissues through the incisions, and the total quantity absorbed is in
this way somewhat reduced. The precaution mentioned elsewhere,
of keeping the patient recumbent with head low for several hours
after operation where large doses of the drug have been used, may
again be emphasized here; also when operating upon an extremity
under similar conditions to intermittently relax the constrictor rather
than removing it entirely at once upon the completion of the operation.
I26 LOCAL ANESTHESIA
Cocain produces a veritable general analgesia as a final stage in
all severe intoxications, but only when the life of the animal is seriously
threatened; this is not only of interest to the physiologist, but to the
surgeon as well. (See General Anesthesia with Cocain.)
The local action of Cocain, aside from its anesthetic action, is that
of a vasoconstrictor, producing a decided degree of anemia; it is
believed that its central toxic action is ushered in by similar phenom-
ena—anemia of the cerebrum and vital nerve-centers, producing
at first a brief period of excitement or irritation, followed by paralysis;
these symptoms may be of mild degree and slow to develop, passing
off without serious results, or appear suddenly and end in a fatal ter-
mination within a few moments, depending upon the size of the dose
and the rapidity of absorption.
Many operators have tried to prevent or lessen this central toxic
action by adding to the cocain solution various drugs to combat this
central vasoconstriction, or by using a combination of anesthetic
drugs have hoped to be able to reduce the quantity of cocain needed
to a point well below the toxic dose, even when large quantities of the
Solution was necessary. Thus, Stuver advised a mixture consisting
of one part of cocain to two parts of antipyrin; Gluck advised car-
bolic acid and Parker resorcin. To combat the vasoconstriction,
Thomas and Guitton have recommended the addition of nitroglycerin.
All these combinations are objectionable from many points, some of
them being irritant and others fully as toxic or depressing. What
is wanted is to simplify rather than complicate the mixtures. The
use of vasodilators having a local action is especially to be avoided,
for many reasons the local anemia is desired and we try to intensify
it by the use of such aids as adrenalin or by the use of cold; this local
anemia, besides increasing its local action, lessens or prevents its central
or constitutional action by prolonging the sojourn of the drug in the
tissues, where its action is weakened or entirely exhausted.
It is also quite doubtful that such drugs are of any value in com-
bating the toxic effects; what is better is to keep well within the limits
of safety, and, should toxic symptoms occur, to meet them by other
more effective means.
The symptoms of mild intoxication may be evident in loquacity,
laughing, or singing, later slight nausea, vertigo, faintness, thoracic
oppression; as the severity of the symptoms increase, the pulse which
at first is stimulated becomes rapid and weak, respiration may be
oppressed or quite rapid, great mental excitement and anxiety may
occur, the patient becoming very restless with twitching or trembling
TOXICOLOGY I27
of the muscles, these symptoms indicating the threatening onset of
convulsions; at times the stage of excitement may manifest itself by
maniacal delirium, the patient becoming violent and uncontrollable;
convulsions with unconsciousness may now supervene and be fol-
lowed by death. During the Onset of symptoms the pupils are usually
dilated, but may at times be contracted. The order and character
of symptoms may vary greatly in different individuals, the stage of
excitement may be absent, unconsciousness coming on at once, fol-
lowed by convulsions. In some cases where the toxic dose is very
large, or the patient is particularly susceptible, death may occur almost
immediately from cardiac inhibition.
The onset of mild symptoms, such as loguacity or faintness, are
usually controlled by having the patient maintain the horizontal
position or by lowering the head of the table; this position should be
continued for half an hour or longer following the disappearance of
all symptoms. The use of drugs to combat poisonous symptoms must
be largely symptomatic. If syncopy occurs, or the heart becomes
weakened, digitalis should be used, preferably given by hypodermic,
while ammonia or amyl nitrite are given by inhalation. For nervous
excitement or convulsions H. C. Wood recommends chloroform by
inhalations, but it would appear that ether should be better, particu-
larly if it be proved that the central action is associated with the same
vasoconstriction and anemia that takes place in its local field of ac-
tion; inhalations of ether, due to the tremendous congestion which it
produces in these parts, should prove of great value, besides stimulat-
ing both heart and respiration and controlling the convulsions;
nitrous oxid would be equally as valuable; amyl nitrite, while pro-
ducing the same congesting effect, would not exert the same controlling
influence upon the convulsions. -
Regarding the use of ether a very interesting report has lately
been published in the “Journal American Medical Association” by
Dr. J. E. Engstadt, which we quote in part as follows:
“In the first few cases I was called on to treat, Strychnin and
morphin in combination were used with a marked benefit. But, as
cases kept multiplying, I found the action of these drugs too slow, and
I decided that there must be something to counteract the poison more
rapidly when life was in extreme danger. It was necessary to find a
remedy that could be administered at any time and be instantaneous in
its action. I soon found ether to be the required drug. This was ad-
ministered as ordinarily given to produce surgical narcosis. Ether
stimulates the vasomotor system, is a tonic to the heart muscles,
I28 LOCAL ANESTHESIA
stimulates the action of the respiratory centers of the brain and of
the pneumogastric nerve, and increases the pulmonary circulation in
the first stages. While cocain inhibits the action of the heart, espe-
cially on the right side, it has also a marked inhibitory action on
the respiratory centers of the brain. Death may occur from feeble
respiratory movements of the so-called Cheyne-Stokes type or
asphyxia. &
“To me ether has proved extremely valuable. It has saved what
seemed hopeless cases. It stimulates the heart and the respiratory
system almost instantly. The pulse becomes fuller at once and of
normal tension. The marked mental excitement is allayed as the
patient goes under the influence of the ether and the effect of the
poison rapidly disappears. The individual regains consciousness as
soon as the effect of the small amount of ether has disappeared.”
To get the best results, the anesthetic is administered only to the
degree of mild surgical narcosis, or, at times, even less than this.
A mask should be employed and the ether given by the drop method.
This is all-important. Given by the old method, the ether would only
add to the danger of asyphixia by excluding air from the venous-
blood engorged lungs.
It is quite interesting to compare the sedative and controlling
influence of ether upon the symptoms of cocain intoxication, as
reported by Engstadt, with the sedative effects of a hypodermic of
cocain upon animals coming out of ether narcosis (although not
operated upon), as reported by Kast and Meltzer in the chapter on
Abdominal Operations.
It was thought for some time that adrenalin lessens the toxic
action of cocain upon the central nervous system, but upon later
investigation this has been found to be in error, and that after the
cocain once enters the general circulation the use of adrenalin may
increase its toxic action; this may be understood when it is considered
that both produce vasoconstriction. Adrenalin greatly lessens the
likelihood of development of toxic symptoms by retaining the cocain
in the field of injection, and greatly intensifying and prolonging its
action there, where it is largely exhausted by action upon the tissues,
but after it has once entered the general circulation the adrenalin
may prove a distinct disadvantage.
The observations of J. M. Berry on this subject are particularly
interesting. He concludes his remarks as follows: “In the use of
adrenalin-cocain care should be exercised not to inject a toxic dose
of the latter, for not only does the adrenalin fail to protect the body
TOXICOLOGY I29
against the toxic doses of Cocain, but it seems to enhance the toxic
action.”
Thriss found, by experiments on cats, that cocain and adrenalin,
when injected into the lumbar sac, had the same toxic effect as when
Cocain was used alone. Miles and Muhlberg, in a series of experiments
upon animals for the study of the comparative value of adrenalin and
other substances upon vasomotor depression artificially produced,
conclude that “adrenalin subcutaneously is indicated on theoretic
ground for the vasomotor collapse following cocain or chloroform
poisoning, etc.” Here, however, it is to be used to combat a symp-
tom, and not in any sense as an antidote.
Braun, in his book on local anesthesia, and elsewhere in the “Ar-
chiv. f. klin. Chir.,” vol. lxix, does not concur in these views, but
believes that adrenalin lessens the central toxic action; on the other
hand, Petrow found that adrenalin did not seem to exert any great
influence upon the toxic action. -
Morphin, while highly valuable as a preliminary injection to all
major operations with local anesthesia for the purpose of preventing
psychic influence, and is a constituent of Schleich's solution, has
probably no value at all as an antidote, and should rarely be used, or
only cautiously, for this purpose. Vaillard condemns the use of
morphin. He concludes: (1) There is no antidote to cocain-poison-
ing. (2) Authorities do not favor the use of narcotics in this condition.
(3) There is no evidence to show that morphin has any neutralizing
effect to warrant its use as an antidote in a case where an overdose of
cocain has been taken, and, under such circumstances, it is not merely
of doubtful benefit, but may prove positively dangerous. (4) The
administration of morphin in a case reported did not prevent death,
but may have exerted a modifying effect upon the terminal convul-
Sions.
The use of intravenous salt injections, as recommended for all
poisons, may be tried for cocain when time permits. The diluting
effects of a pint or quart of normal salt solution should have a favor-
able influence in weakening the toxic strength of the drug, as well as
stimulating the heart and favoring more rapid elimination.
Carlo Bozzo found that the minimum fatal dose of cocain for
dogs, injected hypodermically, was o.o.25 gram per kilo, without in-
fusion, but when infusion was resorted to the minimum fatal dose
rose to o.o.3 per kilo; he concludes that besides favoring rapid elimina-
tion it retards the absorption of further quantities of the drug, owing
to the fulness of the blood-vessels.
9
I3o LOCAL ANESTHESIA
The development of toxic symptoms from the use of cocain may
be considerably delayed, or, after apparent recovery, the patient may
again sink into a state of Syncopy or collapse. As an illustration
of this condition, the author was called to see a case of convul-
sions in a young man twenty-four years old, and obtained the fol-
lowing history: Two hours previously he had had two molar teeth
extracted by the use of local injections of cocain; it was necessary for
the dentist to make repeated injections before securing the neces-
sary anesthesia; the extractions were finally painless; following the
procedure there was slight nausea and Some vertigo, for which he was
given a drink of whisky, when he appeared to recover, and was
able to go home in the street cars a distance of about twenty city
blocks; after arriving at home he felt uneasy and restless and sat in a
chair in his gallery; he was found sometime later by his family, still
in the chair, but in a state of convulsion; when the writer arrived
he had had several such seizures, at intervals of about fifteen or
twenty minutes, becoming quite uncontrollable and violent just be-
fore their onset; as I had learned the nature of the case I went pre-
pared. The patient was frantic upon my arrival, requiring the com-
bined efforts of several of the family to hold him; his pupils were
widely dilated, face very pale, studded with large drops of perspiration,
and his expression one of terror; the respirations were rapid and
shallow, the pulse small, feeble, and rapid. We at once threw the
patient across the bed, where he was held while I administered ether
by the drop method to the point of superficial anesthesia; with the
beginning of the ether administration there was an immediate change,
the respirations deepened, the pulse slowed and became fuller, the
color returning to the face, the muscles which had been tense soon
relaxed; the entire picture was changed, the patient presenting the
usual appearance of one under light ether narcosis; this was kept up
for about fifteen or twenty minutes and gradually suspended. The
feet and hips were then elevated upon pillows until the head was quite
dependent; this position was maintained while the patient came from
under the influence of the ether and for sometime afterward. I
remained with him for about one-half hour after he appeared normal
to make sure that there would be no return of the symptoms, but
beyond a feeling of exhaustion there was no further disturbance. Next
day he appeared quite normal; later examination of his kidneys and
other organs failed to show anything abnormal.
J. K. Pedley reports a case related by Dr. B. Christensen, in which a young woman
aged twenty-eight had the root of a tooth extracted under novocain anesthesia and died
TOXICOLOGY I31
several hours later: “At 1.45 P.M. I injected about 13 c.c. of a little less than a 2 per cent.
Solution of novocian-suprarenin (Tab. B. Containing novocain, o. I gram, suprarenin,
o.oOo.45 gram), but as the anesthesia was insufficient ten minutes later I injected some
more, in all about 3 c.c. The patient felt rather unwell afterward and was advised to
remain in the office and lie down.
“From 4 to 4.30 she was sitting up and chatting; at 5.30 she had so much improved
the doctor left her; at 6.30 his wife noticed her and she seemed to be in a natural sleep;
shortly later noticed her breathing rather deeply and on examination found her almost
pulseless; gave camphor by needle.
“At 7 P. M. doctor returned and performed artificial respiration, at 8 P. M. was removed
to the hospital, and died one hour later, without regaining consciousness, with symptoms
of edema of lungs.”
Cases of this kind could be reported in great number, but the
above will suffice for an illustration.
To recapitulate: With the onset of the first symptoms imme-
diately place the patient in a recumbent position and lower the
head; if the operation has been upon an extremity apply a constrictor
proximal to the field; give ammonia or amyl nitrite by inhalation;
if the case seems severe, lightly narcotize with ether by the drop
method; use digitalis or oil of camphor by needle if the heart is weak;
in severe cases use infusions of normal salt solutions if convenient;
should the respiration cease artificial respiration should be resorted to
and persisted in as long as the pulse or heart is perceptible or even
longer, as there may be a chance of resuscitation. Legrand reports a
case where it was necessary to continue artificial respiration for
five hours before the function became normal. In such cases, where
the facilities are at hand, use the Meltzer-Auer intratracheal intuba-
tion with forced respiration.
Some of the earlier cases of poisoning may have resulted from
the presence of certain impurities in the preparation used, and this
may even occur now, though not so likely, as the methods of manu-
facture and safeguards placed around it have So far improved as to
reduce this likelihood to a minimum.
Some of these impurities have never been determined, but a few
have been isolated and positively identified; two of these, which in the
past have been most likely to occur, are isatropylcocain and cinnamyl-
cocain, both highly toxic; as these impurities act in different ways,
some of the peculiar toxic symptoms reported may be accounted for
in this way.
CHAPTER VII
ADRENALIN
ADRENALIN, the therapeutic Constrictor, known under several
names as suprarenin, paranephrin, epirenin, eudrenal, and epinephrin,
but probably better known in this country as adrenalin, the name
proposed for it by Takamine (and the synthetic preparations of
arterenol, homorenon, and suprarenin synthetic), are powerful local
and constitutional vasoconstrictors, and, except the latter, obtained
as an extract from the suprarenal glands of animals.
The introduction within the last ten years of this highly valuable
and wonderful agent has proved a great boon to many departments
of surgery, and has given a decided impetus to all local anesthetic
procedures. Next to the possession of safe local anesthetics and the
Schleich infiltration method (with dilute solutions), there is no single
agent or factor which has fostered and encouraged the development
of local anesthesia, and enabled surgeons to enlarge the field and
broaden the scope of all purely local procedures.
This has been made possible by the unique power this agent
exercises of producing vasoconstriction, and retaining within the
tissues the dilute anesthetics which both intensifies and prolongs
their action for a period of time usually well beyond that required
for the performance of any ordinary operation, and that without
injury to the tissues.
To Prof. Heinrich Braun, of Zwickau, Germany, from whom we
have quoted quite liberally in this volume, is largely due the credit of
first introducing, developing, and perfecting the use of this agent
in local anesthesia. Already a staunch advocate of local anesthesia,
in which field he has been a constant worker, he was quick to see the
advantages of a combination with adrenalin and early advocated its
use, and it is largely due to his efforts in this direction that adrenalin
became so popular an adjunct in all local anesthetic solutions so
shortly after its introduction.
Adrenalin has become almost indispensable to the surgical spe-
cialists, particularly in the nose and throat, where it is in constant
daily use, both for purposes of examination as well as for operations;
in examinations it greatly facilitates the procedure when Swabbed
or sprayed on turgid and congested mucous passages, causing them
132
ADRENALIN I33
to shrink and permit free access and inspection of the deeper parts.
Nearly all operations upon these parts are greatly facilitated and
simplified by its use, which renders the field almost entirely bloodless,
thus greatly expediting the work, which enables the operator to under-
take many operations in the office without assistance under local anes-
thesia and without the loss of any blood, which formerly were done
Only in institutions under general anesthesia, with considerable loss
of blood and a much more complicated and tedious technic.
The history of the early work which led to the discovery of adren-
alin is not without interest, but only brief mention will be made
of it here in expressing our gratitude to those who have given us this
valuable agent. Early anatomists observed that the juice of the medul-
lary Substance of the Suprarenals darkened upon exposure to light and
air; they called this substance atra bibis. It was not, however, until
the nineteenth century that the color change was understood. Vul-
pian in 1856 noticed that this juice, when brought into contact with
ferric chlorid and iodin, turned emerald green and then rose carmin.
These reactions were characteristic of this organ, and led to the
opinion that the gland contained a physiologic substance.
Pellacani, as early as 1879, performed a very interesting series of
experiments in Foa's laboratory by injecting an extract of the fresh
glands into various animals. Mattei later repeated Pellacani's experi-
ments, and came to the conclusion that his results were those of
septicemia rather than from any special active principle of the gland.
In 1883 Foa and Pellacani again took up the study and published
Some interesting results, and it would seem, after reading the original
papers of these early writers, that more credit should be given them,
for they certainly describe symptoms of poisoning which are now
recognized as characteristic of adrenalin.
Other investigators followed up this line of work: Krukenberg
(1885), Marino-Zuco (1888), Guarnieri and Marino-Zuco (1888).
The synthetic preparation of this agent began to be foreshadowed
as early as 1893 by the work of Dr. Zierzgowski, who should be given
credit for pioneer work in this line.
Gluzinski (1895), Moore (1895), Dubois (1896), and Vincent
(1897) were other workers with these glands. In 1896 Fränkel Sug-
gested sphygmogenin as a name for the active principle of the gland;
this was, however, later shown to be a mixture.
The work that had been done by the earlier investigators pre-
pared the way for that which was to follow; the subsequent investiga-
tions began to yield better results in isolating the active principle of
I34 LOCAL ANESTHESIA
these glands. Dreyer had also been able to isolate the active prin-
ciple of the suprarenals in the veins coming from these glands.
Batelle (1902) claimed to have obtained a purer adrenalin than
that produced by Takamine's method.
In the meantime enough data had accumulated to attempt the
synthetic preparation, although, as has been mentioned, Dzierz-
gowski in 1893 had done creditable work in this line. Stolz suc-
ceeded in producing the so-called dl-product, which was found to be
somewhat different from the natural base. This was found by Flacher
to be due to dextro and levo components which he was able to sepa-
rate, and found that the levo-adrenalin was identical with that ob-
tained from the glands. The action of this principle began now to be
extensively studied, and Cybulskilgo pointed out that concentrated
doses were much more poisonous than when diluted; and Gluzinski
determined that intravenous doses were more toxic than subcutaneous.
The physiologic investigators began now to become more numerous,
and the literature of this subject is filled with the names of prominent
investigators.
In 1895 Oliver and Schäfer, and Szymonowicz and Cybulski,
working independently, discovered the action of certain suprarenal
bodies upon the circulation.
Abel in 1897, working along the same lines, was able to isolate
a body which he called epinephrin.
In 1900 Von Furth described Suprarenin, and in 1901 Takamine
and Aldrich isolated a principle which Takamine called adrenalin.
It is probable that these two last substances are identical, while
epinephrin seems to be different both chemically and physiologically.
Abel regards adrenalin as an epinephrin hydrate.
Investigations regarding the relative merits of the synthetic
preparations (dl-adrenalin, known commercially as arterenol, and the
ethyl-amino-aceto-catechol, known as homorenon) conclude that the
former is about two-thirds as active as the natural product and the
latter about one-eightieth as strong.
The chemical formula of adrenalin, as analyzed by Stolz, Aldrich,
and others, is given as C.H.O.N and graphically expressed—
OH OH
| |
/CN /CN
H- g-on H–C C–OH
H–C C–H Or H–C C–H
NC/ NC/
| /OH | 2H
ČečH.NHCH, éNHCH,
NH NCH off
ADRENALIN I35
the former of which is generally accepted as correct. Following the
analysis, adrenalin has been synthetically prepared; these synthetic
preparations have, however, until lately found little favor in this
Country, but have become popular abroad.
Adrenalin is easily affected by light, which decomposes it; it is,
therefore, always best kept in the dark and in dark-colored bottles.
When decomposing it first becomes faintly rose colored, then of a
brownish-red color and turbid; when in this condition it should never
be used, as it may be irritating or even poisonous; only absolutely
clear and colorless solutions should be used.
That part of the physiologic action of adrenalin which concerns us
here is limited to its action upon the circulation in any given opera-
tive area when locally used. For a consideration of its highly inter-
esting action in other spheres of its influence, particularly its consti-
tutional effect in its many clinical uses, the reader is referred to the
various articles which deal with this subject. (See especially Crile,
Boston Med. and Surg. Jour., March 5, 1903, and Amer. Jour. Med.
Sciences, April, 1909; Miles and Mühlberg, Cleveland Med. Jour.,
Dec., 1902; also Winters, Lancet, June, 1905, and others.)
Only such clinical illustrations will be mentioned here as will
serve to emphasize its great power as a vasoconstrictor, and, under
certain conditions, a stimulant to all smooth muscle-fibers.
The action of adrenalin in constricting the blood-vessels is both
local and constitutional; the latter effect is quite general through-
out the body; its local effect is best studied when injected locally in
dilute solutions, when it produces a high degree of anemia of marked
duration; that portion of the drug absorbed exercises a constitutional
effect. Lehman found that by injecting solutions of adrenalin into
the liver of experimental animals he was enabled to excise large
sections of this organ without loss of blood; this marked anemia
lasted thirty to forty minutes and was not followed by secondary
hemorrhage. This vasoconstrictor action does not seem to depend
upon any influence upon the vasomotor nerves, but is no doubt due
to direct action upon the smooth muscle-fibers in the vessel walls, as
shown by the following experiments. Crile was able to keep the
heart of a decapitated dog acting for over ten hours by the action of
adrenalin and saline solution upon the heart and blood-vessels, and
in sufficient dosage to be able to produce a marked rise in blood-
pressure even when the vasomotor center was proved to have been
exhausted (complete shock); the same result was produced when the
center was cocainized or had previously been destroyed; it also OC-
I36 LOCAL ANESTHESIA
curred after the division of both vagi and both accelerantes when the
animal was under the influence of curare. It was also noted during
these experiments that adrenalin was capable of constricting the
blood-vessels after the circulation had ceased. -
Animals killed by asphyxia, and apparently dead for periods up
to fifteen minutes, were restored to conscious life again by artificial
respiration and the simultaneous injection into the jugular vein of
adrenalin and Salt Solution.
The circulation and respiration of dogs electrocuted by a shock
of 23oo volts of an alternating current were again re-established by
injecting adrenalin solution into the circulation.
During these experiments it was determined that adrenalin was
rapidly oxidized by the solid tissues of the body as well as by the
blood. -
Animal experimentation conducted by writers under slightly dif-
ferent conditions showed similar results.
From these and similar experiments it is concluded that the
action is a direct one exercised upon the smooth muscle-fibers in the
vessel walls; all smooth muscle-fibers seem influenced in a similar
way, though not always to the same degree (Jacoby and Schäfer).
It is found to exert a marked influence upon the uterine muscles, as
illustrated in a case of Cesarean section operated on by Bogdanovics,
in which, after the delivery of the child, the uterus was found flabby
and inert. The uterine wound was first closed and I c.c. of a I: Io,000
solution of adrenalin injected into the uterine walls at four different
points; this at once excited muscular action and the contracted uterus
became as hard as stone.
The blood-vessels of the different organs are not all influenced to
the same degree; the action on the vessels of the skin is most marked,
less so in the gastro-intestinal tract and bladder, and hardly at all
in the vessels of the lungs (Langley). The urine of animals injected
with large doses of adrenalin is capable when injected into other
animals of raising the blood-pressure; but it would seem that this
agent is very largely destroyed in the body, very little of it being ex-
creted. Ott and Harris, Meltzer and Auer found that by mixing
strychnin with adrenalin before injection into frogs the toxic ac-
tion is both delayed and diminished; this observation is of great
practical value in local anesthesia, as will be presently pointed out.
A similar favorable action of adrenalin has been noted in the
treatment of snake-bite in 3 cases recently reported by Drs.
Hooker, Menger, and Ferguson, all occcurring in the state of Texas.
ADRENALIN I37
In 2 cases the Snake was a rattler, in the other case a moccasin.
All bites were upon the extremities, and occurred from one to two
hours before treatment. Various procedures were resorted to—scari-
fication or incisions into the wound, injections of permanganate, with
the use of a constrictor reported in I case—but all were treated with
adrenalin in addition, injected into the tissues near the site of the
bite. All cases recovered in a short time without any notable local
or constitutional after-effect; the adrenalin was largely given the credit
for their favorable termination. It is probable that in these cases the
adrenalin, through its vasoconstriction, retains the snake venom
in the parts locally until it is largely oxidized or destroyed by action
upon it of the tissues.
Dr. K. C. Bose, of Calcutta, gives his experiences in the treat-
ment of enlarged spleens, where he claims invariably satisfactory
results. Tremendous enlargements have yielded to 5-drop doses
three times a day, continued for a period of several weeks. Interest-
ing and somewhat similar experience was reported by Dr. Tarry, of
Long Beach, Miss. Another practical clinical application of adren-
alin, which illustrates in a striking way its local action upon the
vascularity or congestion of a part, is readily seen in urethral stric-
ture, particularly of the deep urethra; tight strictures of these parts,
when it seems almost impossible to pass even a filiform, if first treated
with adrenalin (about 5 to Io drops of a 1:5000 solution), deposited
in the urethra with an urethral instillator just in front of the struc-
ture and allowed to remain about ten minutes, will often so relieve
the congestion of the parts, which is always a contributing factor in
strictures, as to fairly easily permit the passage of a moderate-sized
instrument. Further clinical applications could be enumerated in
great numbers, but the above will suffice to illustrate its highly
valuable local action as a vasoconstrictor.
Before, however, concluding these illustrations a few remarks may
be made regarding its highly beneficial and useful action in certain
rectal conditions, notably hemorrhoids. In this condition, when the
parts are badly swollen and congested, which increases their irrita-
bility, marked relief may be obtained subjectively and objectively by
the use of adrenalin, either alone or combined with other indicated
agents in ointment form, which relieves the congestion, causing the
parts to shrink and assume a more normal aspect.
In all operations upon these parts when they are badly congested
and bleed freely, either under general or local anesthesia, the injec-
tion of adrenalin solution is always of decided benefit; under general
I38 LOCAL ANESTHESIA
anesthesia the injection of a few syringefuls of a solution of Io drops
to the ounce distributed in the field will prove of decided aid.
Hurter and Richards, as well as others, have demonstrated that
this agent in large doses or when repeatedly used will produce a
glycosuria.
Vincent claims that this agent is a muscle poison, death resulting
from the use of large doses by paralysis of respiration with small weak
pulse, which follows a short period of high blood-pressure.
The dose of adrenalin should be carefully considered, as large
doses are very dangerous; the greater the concentration the greater
the toxic action. In very dilute solutions a much larger quantity can
be safely given; the toxic dose is naturally much smaller when given
intravenously than when subcutaneously administered.
Batelle, Bouchard, and Claude give the toxic intravenous dose
for rabbits as o.oOo.1 to o.oOo.2 gram per kilo, while the Subcutaneous
toxic dose is o.o.o.2 to o.o.2 per kilo. Batelle states that the toxic dose
subcutaneously is forty times greater than the intravenous.
The degree of action of this drug depends entirely upon the strength
of the solution. While a decided influence is obtained by remarkably
weak dilutions, the use of stronger solutions will absolutely obliterate
the lumen of vessels the size of the palmar digital arteries and even
larger, so that not a drop of bloodwill escape from their cut ends while
the adrenalin remains in action.
It is, however, never necessary for our purposes to use strong solu-
tions, as a very decided influence is produced by very dilute solutions.
Moore and Purinton found that the blood-pressure of dogs was
noticeably increased by doses as Small as o.oOo,ooo,245 to o.oOo,024
gram of the extract per kilo of dog weight.
In animals experimented upon with toxic doses, after a short
initial rise of blood-pressure, there is a collapse of the vasomotor
system with Small rapid and feeble pulse, paralysis of the extremities,
tonic and clonic spasms, opisthotonus, mydriasis, rapid respiration,
edema of the lungs, anemia of the abdominal organs, and death
usually from paralysis of respiration.
Its continuous injection in small doses produces in animals ex-
perimented upon calcareous degeneration of the heart, aorta, and
great vessels with glycosuria.
The experiments carried out by Braun with adrenalin upon himself
during 1902 are given in his “Die Lokal Anesthesie,” and are as
follows: He injected under the skin of his forearm adrenalin solu-
tion I: Iooo in increasing doses; with a little over # c.c. constitutional
ADRENALIN I39
symptoms were noticeable. He states: “Five minutes after injection
I had a feeling of oppression in the breast, cardiac palpitation with
quickened and deepened respirations; the number of heart-beats
rose from 64 to 94 per minute. I was compelled to lie down, although
after one and a half minutes the symptoms disappeared; there was no
glycosuria. When I diluted the adrenalin solution with ten times
the quantity of normal Salt solution, I was able to increase the quan-
tity injected to I c.c. before any effect was observed.”
The pronounced effect exercised by adrenalin in delaying the ab-
Sorption, and consequently the constitutional action and excretion
of any Substances or drugs injected into the tissues in combination
with it, is best studied when the adrenalin is used with some agent

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e° • ee e” **ee.
e°
w-r- ºr w w ºr
4. 2. 3. 4. J. 6. 7. 8 Hours.
Fig. 2.-The influence of adrenalin on the excretion of milk-sugar in the urine following
its subcutaneous injection: - without, ..... with adrenalin, after Klapp (Braun).
little or not at all affected by its passage through the system. This
action is strikingly illustrated by the following experiment of Klapp
with the use of milk-sugar, first carried out as a control experiment
without adrenalin, and later repeated under identical conditions with
the addition of adrenalin.
A dog was injected subcutaneously in the region of the back with
Io c.c. of a 6% per cent. milk-sugar solution, and the excretion of the
Sugar through the urine studied from hour to hour. Three days
later the same quantity of the same solution, with the addition of
2 drops of adrenalin I: Iooo, was similarly injected and the excre-
tion by the kidneys studied in the same way.
A study of Fig. 2 will give in a schematic way the results of this
experiment. It will be seen at a glance that the maximum excretion
I4O LOCAL ANESTHESIA
of Sugar without adrenalin, as indicated by the heavy line, begins
immediately after the injection and reaches its maximum intensity
within the first hour, when it rapidly falls off and entirely ceases
after the sixth hour, by which time a total of o.569 gram had been
recovered from the urine. -
The dotted line indicates the absorption and excretion of the
sugar under the local influence of adrenalin, and presents a striking
and interesting contrast to the former in the following points: Dur-
ing the first hour, in which the maximum is excreted without adren-
alin, absolutely none was recovered when the adrenalin was used,
the excretion not beginning until the commencement of the second
hour; from this time it slowly increases, reaching its maximum at the
end of the fifth hour, and that at this maximum point of excretion
the amount was one-half that recovered during the interval of maxi-
mum excretion without the use of adrenalin; further, that the ex-
cretion is prolonged over a very much longer period, as traces were
still found in the urine at the end of the eighth hour, when the ob-
servations were discontinued, after a total of o.343 gram had been
recovered.
In the strengths ordinarily employed its use is not followed by
any after-reaction; there is not hyperemia, but the tissues gradually
resume their normal vascularity, and there seems to be no retarding
or injurious action upon the healing of wounds; when slightly more
than the dose to be recommended has been used, it has seemed to
the writer that there was more after-pain in the wound than would
have been the case under other conditions associated with a reac-
tionary hyperemia.
As ordinarily used by the author for infiltration, the dose should
never exceed 5 drops of a 1: Iooo solution to the ounce of the anes-
thetic fluid, and less than this, 2 or 3 drops, will be found amply
sufficient. - :
It is well in all large operations to estimate about the total quantity
of the anesthetic solution likely to be needed—say, for a rather large
hernia, 4 to 6 ounces may be required; this is measured off and put in
a convenient receptacle, and to this total quantity about 15 or 20 drops
of the adrenalin solution (I: Tooo) is added; in this way we know ex-
actly how much is being used and the safe dose need not be exceeded;
we obtain by these weak dilutions all that can be accomplished by
stronger doses, and without noticeable constitutional action or other
ill effects. As the action of adrenalin is immediate it is not neces-
sary to wait to obtain this influence, but a delay of five to ten min-
ADRENALIN I4 I
utes is usually necessary after the infiltration to obtain the full anes-
thetic effect of the drug used. When the incision is made the first
effect noticed will be the anemia of the parts, practically no blood
being lost except from the mouths of divided vessels. When adrenalin
is used in the above-mentioned strength this anemia lasts approxi-
mately one hour; this is influenced to a considerable extent by the
normal vascularity of the part; it is consequently of shorter duration
about the face and in abnormally vascular parts; in these parts the
maximum dose, 5 drops to the ounce of anesthetic solution, may be
found necessary.
The advantages of this anemia are the greater facility and freedom
with which delicate dissections may be performed in a comparatively
bloodless field. Aside from the hemostasis, the most notable gain
derived from the use of adrenalin is its power to retain the anesthetic
agent within the tissues for a considerable length of time, from three-
quarters of an hour to an hour and a half in the strength above men-
tioned (not over 5 drops to the ounce of Solution); when stronger
solutions are used this anemia and prolongation of the anesthetic
action of the agent used may be considerably extended—as long as
three or four hours in Some cases.
This retention within the tissues intensifies the anesthetic action
and lessens the likelihood of repeated injections being necessary
in a prolonged operation, thus avoiding the trauma of repeated infil-
trations upon the tissues, and eliminating the possible toxic action
of such repeated infiltrations, as well as lessening the likelihood of any
toxic action developing from the solution injected by retaining it in
the tissues for such a long period of time that its activity is largely
weakened or destroyed, and when absorption does occur it is SO
gradual that no constitutional effects are to be noted. This permits
the use of much more extensive infiltrations than would otherwise
be safe without the addition of adrenalin; in this way we have repeat-
edly made use of 8, Io, 12, or more ounces of Schleich solution No. 1,
or our solution No. 1, in extensive operations without once having
seen any toxic effects arising from the large quantity used. Of course,
in all operations under infiltration a certain variable quantity of the
solution infiltrated escapes through the incisions, which to Some
extent lessens the total amount of the drug finally absorbed. -
Ordinarily, in operations upon the peripheral parts of the extremi-
ties under local anesthesia, with the addition of adrenalin, the constric-
tor may often be dispensed with, except for hemostatic control of the
larger vessels, as in amputations, when it should always be used.
I42 LOCAL ANESTHESIA
When used in these operations it should always be applied after the
infiltration or nerve blocking has been completed; in the case of the
latter procedure it may be necessary to apply it below the point of
the nerve injection, but in case of infiltrations it should always be
applied proximal to the field of infiltration. When used in this way
with adrenalin it intensifies both the action of the adrenalin as well as
that of the local anesthetic used (the anesthesia is probably also
contributed to by the fact that anemic tissues are always less sensi-
tive than vascular), and prolongs indefinitely the local anesthetic
action of the agent used as well as the adrenalin; this prolongation of
the action of these agents in this way is only limited by the time that
the constrictor may safely be allowed to remain in position (from
one to two hours, depending upon the age of the patient and condition
of the parts locally). A very important point in the technic in operat-
ing in any field with the use of adrenalin is to make ample provision
for hemostasis after the effects of the adrenalin have subsided; bleed-
ing points which barely permit a capillary ooze at the time of opera-
tion may, after the vasoconstriction subsides, give rise to a rather
free hemorrhage; for this reason, it is absolutely necessary to secure
and ligate all visible bleeding points, and leave no dead spaces for the
accumulation of hematomas; this may be accomplished by approximat-
ing the different planes of tissues, as in a herniotomy, by anchoring
the overlying plane to the one beneath by occasionally passing the
suture down and catching a bite in the plane beneath, thus uniting
the various layers at the suture line and preventing a possible space
for the accumulation of ooze. In operating upon very loose tissues,
as the scrotum, it is very essential to finish the operation by a firm
Supporting dressing, held Snugly in place by a well-fitting suspensory.
In operations within the nasal cavity, and in such wounds as are left
open, postoperative bleeding should be guarded against by the proper
use of packs.
All the agents in use as local anesthetics are not equally effected
by adrenalin; this degree of influence varies with the different agents.
Beta-eucain is affected to a less extent than cocain and the same
with stovain, while with tropococain it has little or no effect. Novo-
cain is decidedly affected, its action being greatly intensified and pro-
longed by its addition.
Other effects noticed by these combinations are that when used
with cocain, which has a slight vasoconstrictor effect, that the result-
ing anemia is slightly more marked than with Such agents as novocain
(Fig. 3).
ADREN ALIN I43
Large operative fields can be rendered completely bloodless by
its use; here it is not necessary to thoroughly saturate the entire field
with the solution, but to make the injections in a peripheral or cir-
cumferential manner around the field, as with the Hackenbruch plan
for local anesthesia, or only in the directions from which the circula-
tion enters, thus constricting all vessels which enters the operative
area; this use of the agent may often be of value when operating
upon very vascular areas even under general anesthesia.
- g 2
14–14—º-i-A 400
l #. # .." 2
! * %, %. —rt © l_ſ 90
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7–3–7–7; ; – 3–2–3–2–z-z-z-z-z
Fig. 3.-Illustrating diagrammatically the action of adrenalin in combination with
different anesthetics (after Läwen): A, Adrenalin; B, adrenalin with cocain; C, adrenalin
with eucain; D, adrenalin with tropococain (Braun).
To obtain this perfect anemia in operating upon the extremities,
unless at the extreme distal parts, it will be necessary to make the
injections on the distal as well as the proximal side of the field, to
influence, on the one hand, the veins; on the other, the arteries as
they enter the field.
The synthetic preparations, such as arterenin, homorenon, and
suprarenin synthetic, are found to be identically the same in formula
and action as adrenalin. Braun found that homorenon was about
fifty times less toxic and fifty times less active than adrenalin, and
does not cause any injury or irritation to the tissues.
I44. LOCAL ANESTHESIA
The synthetic preparations of adrenalin have until recently been
little used in this country, Surgeons preferring the natural product,
which had so far proved best and has answered all requirements; all
that the synthetic chemists have attempted is to imitate adrenalin,
none have surpassed it. The comparison of these synthetic prepara-
tions with adrenalin has been undertaken by some observers, thus,
Biberfeld states that synthetic Suprarenin is identical both by quali-
tative and quantitative test with the natural preparation, while
arterenin seemed slightly weaker, at least in rabbits, the toxic dose
being two or three times greater. Braun, who has experimented with
both solutions, finds them in I: Iooo dilutions about equal to the
natural preparations; both preparations possess certain qualities
in common with the natural preparation; they must be kept in slightly
acid solutions (HCl); they have but a limited stability, and must not
be used when cloudy or discolored. Regarding the synthetic prepara-
tions of homorenon Braun has much to say in favor of it; it is quite
soluble and stable and presents identical pharmacologic qualities
with adrenalin, but about fifty times weaker in action and fifty times
less toxic. A 5 per cent. homorenon solution is, therefore, equal to a
I: Iooo solution of adrenalin, and produces a vasoconstriction equal
to that of corresponding strength. When used intracutaneously
and subcutaneously it produces no irritation or after-reaction.
That ideal synthetic preparations of the adrenal glands will
eventually be obtained which will entirely replace the animal ex-
tracts is to be expected, as has been the case with local anesthetics,
novocain representing the greatest and latest achievement in this
line.
The animal extracts have many disadvantages, principally their
lack of stability, inconstancy of action, the inability to properly
sterilize them by heat, and their cost, which, when considered with
their poor-keeping qualities, makes this cost relatively greater.
The latest achievements in synthetic adrenalin is suprarenin
synthetic; this agent has now been very thoroughly tested, and
seems to meet all requirements and demands made upon it. In I: Iooo
solution, as ordinarily used, its rapidity, intensity, and duration of
action compare very favorably with the natural product, some ob-
servers claiming for the synthetic product slight advantages.
It is further capable of a fair degree of sterilization by heat (boil-
ing from three to five minutes); it is more stable in keeping qualities
and is cheaper.
While the writer has had but a limited experience with this prepara-
ADRENALIN I45.
tion the reports from others are rather encouraging, and it gives
promise of fulfilling all requirements exacted of it, and will, if further
experience justifies these claims, largely, if not entirely, replace the
organic preparations.
The following experiments, reported by Braun in his book on
local anesthesia, should be compared with similar experiments made
by the same author with similar solutions, but without the addition
of adrenalin, and quoted on page 87. (See chapter on Local Anes-
thetics.)
“(1) To Ioo c.c. of a I per cent. alypin solution 5 drops of adrenalin
(1: Looo) were added. With this solution an intradermal wheal is
formed; the injection is painful. No hyperemia occurs, but the
adrenalin anemia develops to full extent. The white wheal lies within
an area covered with large white blotches. The anesthesia lasts for
about two hours, when the sensibility gradually returns. An hy-
peremic infiltrate remains at the point of injection until next day.
“(2) o.5 per cent. Solution, with the addition of o.8 per cent.
sodium chlorid.; I c.c. of this solution, to which has been added I drop
of I: Iooo adrenalin, is injected in a circular manner into the subcu-
taneous tissue at the base of the fourth finger.
“The injection is painful; after ten minutes the entire finger as
far as the tip is entirely anesthetic. After two hours the sensibility
begins to gradually return, and after three hours is completely normal.
“The base of the finger remains red, infiltrated, and painful for
several days; o.5 per cent. cocain or eucain solution with the same
addition does not produce this final phenomena.
“(3) I per cent. isotonic novocain solution and 5 drops of adren-
alin solution (I: Iooo) to each Ioo c.c. The formation of cutaneous
wheals on the forearm by intradermal injections were painless and
produced a very pronounced anemia. The duration of the anesthesia
lasted longer than an hour and left no reaction.
“(4) I per cent. novocain solution with 2 drops of I: Iooo
adrenalin to each cubic centimeter. Formation of wheals on the
forearm; injection painless. The anesthesia, which extended con-
siderably beyond the limits of the wheal, lasted about four hours.
The action of the adrenalin is very marked.
“After subsidence of the adrenalin anemia Some after-pain results
at the site of injection. No other reaction.
“(5) # c.c. of the same novocain-adrenalin solution was injected
subcutaneously in the forearm. The skin over the point of injection,
as well as the distribution of the sensory nerves which passed through
10
I46 LOCAL ANESTHESIA
the injected area, was insensitive to pain for from two and a half to
three hours. Pronounced adrenalin influence. No reaction.
“(6) o.5 per cent. novocain solution with the addition of I drop of
adrenalin (I: Tooo) to each cubic centimeter; I c.c. of this mixture was
injected subcutaneously in a circular manner around the base of the
fourth finger. After ten minutes the entire finger is anemic and
insensitive.
“After sixty-five minutes sensation begins to return in the finger-
tip, requiring a full hour for the complete return of sensation. There
was no after-pain or Swelling.”
In conclusion, a few words regarding the dose of adrenalin: Io
minims is about the safe maximum dose which should be thrown into
the circulation of a normal healthy adult at any one time, but as
the dose varies with the concentration this amount may be exceeded
when largely diluted and distributed over a large area, as in infiltra-
tion, from which it will be slowly taken up. The dose should vary
according to the age and condition of the patient, childhood, old age,
arteriosclerotics, and those suffering from lesions of the vascular
system, high blood-pressure, Graves’ disease, etc., are more sus-
ceptible to its influence. The dose in these cases should be lessened
accordingly.
CHAPTER VIII
PRINCIPLES OF TECHNIC
GENERAL CONSIDERATIONS
IN considering in its broadest sense the advisability or utility
of performing major operations under purely local methods of anes-
thesia, as opposed to the use of cerebral anesthetics, one must consider
primarily the risk to the life of the patient.
Notwithstanding the many advances that have been made in the
administration of general anesthetics, particularly in the adminis-
tration of ether by the open method, the risk from general anesthetics
remains relatively high. Many well-appointed institutions, where
the anesthetics are given by professional anesthetists, are able to
present large series of cases, Io,000 to 15,ooo, without a death, but
these are exceptional illustrations, and cannot be accepted as repre-
senting the average conditions which prevail in the great majority
of institutions, or which occur during the administration of anes-
thetics outside of institutions. -
We had been led to believe that due to our improved methods and
the diffusion of knowledge regarding the administration of anes-
thetics the mortality, both primarily at the time of the administra-
tion and secondarily due to the renal, pulmonary, and other compli-
cations directly traceable to the anesthetics, had been very mate-
rially lessened of late. This has been largely dissipated by the report
of Neuber to the Surgical Congress of 1909, in which he shows that the
mortality remains about what it was many years ago. Many of the
more recent statistics published represent results in large surgical
centers, where the administration of anesthetics is largely in the hands
of experts and cannot be accepted as representing the general results.
Neuber collected many thousands of cases (previously published and
unpublished), and was able to show that the deaths from chloroform
average I to 2060 and those from ether I to 5930, thus raising the
mortality to about where it stood a decade ago.
“In view of the preceding fact, is it not proper that while we are
seeking by every means suggested by reason, ingenuity, and expe-
rience to minimize the dangers of these necessary evils—general
147
I48 LOCAL ANESTHESIA
anesthetics—that we also continue to develop and perfect the various
methods of local and regional anesthesia, which permit us to accom-
plish the same results without peril to the organism or injury to the
part involved? If this great desideratum can be realized in a con-
stantly increasing number of Surgical conditions by a skilful and
judicious application of cocain and its succedanea, why not resort to
these methods oftener whenever they can be advantageously applied
and thus help to eliminate, or at least diminish, one of the greatest
sources of anxiety in surgical practice?” (Matas).
Admitting that local methods of anesthesia possess certain disad-
vantages to the operator, in view of the increased time required and
the greater attention often necessary to bestow upon the patient,
such methods of operating will always be unpopular in very large
clinics, where a large number of cases are operated daily; still the ad-
vantages to the patient are often so great as to make local methods of
operating the method of choice in many cases.
To the great majority of operators, whose patients are brought
into the operating-room before being anesthetized while the opera-
tor waits the completion of anesthesia, this loss of time is unnecessary
with local anesthesia, as the operator may begin the anesthetizing
process at once, and with many of the commoner performed opera-
tions the actual time spent in the operating-room is no greater than
under general anesthesia.
We must also face the broad proposition of whether or not it is
desirable that the patient retain consciousness during the perform-
ance of the operation. Obviously, if we took the view that such con-
sciousness was wholly undesirable, except in minor operations, it
would be a serious objection to local anesthesia, but such is not the
case, particularly where Small doses of morphin and scopolamin are
used beforehand, as we advocate in all major procedures, which allays
anxiety and uneasiness. There are many patients who dread more
than anything else the loss of consciousness, and many who have
once had a general anesthetic do not care to repeat the experience.
The great majority of our cases operated under local anesthesia
come to us especially for this purpose, and many operators are able
to attract a large clientele by the skilful development of purely local
methods and prefer local anesthesia for all suitable cases. Köhler
almost invariably uses it for the removal of the thyroid gland. Cer-
tain other desiderata are, however, essential, besides a knowledge
of the purely technical procedures; these are, first of all, a thorough
knowledge of the nerve-supply of the part; local anesthesia makes of
PRINCIPLES OF TECHNIC I49
the surgeon especially a nerve anatomist; other essentials are gentle-
ness and patience on the part of the operator; rough handling and
gross dissections, often indulged in under general anesthesia, should
be avoided here.
“We are also convinced that an unfounded and unjustifiable
skepticism still prevails among many excellent, skilful, and other-
wise progressive surgeons, who, having neither the inclination nor the
patience needed to acquire the latest, most advanced, and efficient
methods of local anesthesia, or still confusing the imperfect and
dangerous methods of the past with the safe and efficient methods
of the present, still doubt and cling to general narcosis as the only
means of abolishing pain in their operations. Others, again, who
have not familiarized themselves with the more recent applications
of regional anesthesia in major surgery will occasionally perform
minor or Superficial operations, such as the removal of a wart or the
opening of an abscess, but will smile with incredulity if in a case re-
quiring the amputation of a limb some one suggests the propriety
of using cocain as the anesthetic. There is still a lingering tendency
on the part of many surgeons, and especially the more conservatively
inclined of the past generation, to regard those who practice local
anesthesia in major surgery in the light of experimentalists or enthu-
siasts, and to class them, as a whole, among the impractical class
of surgeons. To dispel this illusion, and to demonstrate that the
value and efficiency of cocain and its allies are not restricted to the
purely minor or superficial cases that occur in Surgical practice, but
that they are still of greater service in dealing with many of the
gravest and most critical emergencies of Surgery, in which the rôle
of the anesthetic is of paramount importance, will be the object of our
endeavor in this volume” (Matas).
We must also consider that had the discovery of local anesthesia
preceded instead of followed that of general anesthesia, it would cer-
tainly have now been established on a firmer foundation and its
principles more generally understood, instead of having to contest
with general anesthesia to displace it in certain cases from its firmly
entrenched position.
SOLUTIONS AND THEIR METHODS OF USE
The following quotations are from the report of Prof. Matas on
“Local and Regional Anesthesia,” Louisiana State Medical Society,
April, 1900:
“To the student of American surgical history it will be a source
I5o LOCAL ANESTHESIA
of pleasure to recall the fact that probably the first clinical demon-
stration of the value of cocain, when used by the subcutaneous method
for purposes of surgical anesthesia, was made by American investiga-
tors. Beginning with the earlier experiences of Hepburn (November
15, 1884), of Hall and Halsted (December 6, 1884), and of J. Leonard
Corning (1885–86), it is gratifying to note that the essential and
fundamental principles upon which rests the most effective technic
in cocain anesthesia had been foreshadowed, and in Some particulars
completely elaborated, by these early pioneer efforts of American
surgeons.”
Before attempting a further discussion of the subject, it will be
well to present a brief statement of the discoveries which have exer-
cised the most potent influence in widening and perfecting the meth-
ods of local and regional anesthesia.
(1) “The discovery that anesthesia of the skin or derm proper
by intradermal infiltration with cocain or similar analgesic agents,
as distinguished from the hypodermal method, is the key to Success
in local anesthesia, i. e., the anesthesia of the field of operation.
This fundamental fact seems to have suggested itself at the same time
to several observers, but the names of W. S. Halsted (1884), J. L.
Corning (1885), Reclus and Ich Wall (1886), and Schleich (1890) are
the first and most prominent that occur in the literature on the sub-
ject, though Halsted was the first to insist upon the importance of
the intradermal method and to demonstrate by a large clinical expe-
ºrience its great practical importance.”
(2) “The discovery that the tissues are sensitive to the anesthetic
action of extremely dilute solutions of cocain and other analgesics
(1: 20,000 parts, Schleich, Heinze), and that these can be used effect-
ively in exceedingly weak and positively non-toxic doses.
“Corning showed the effectiveness of solutions (warm) of ; of I
per cent. cocain in 1885. Reclus rendered great service by his for-
cible and constant pleading in favor of solutions not stronger than
I per cent., which he used as early as 1885; but to Schleich belongs
the great credit of reducing the strength of the surgical solutions to
#, Po, and Tłºw of I per cent. His experiments began in 1888, but
their value was not fully recognized until the publication of his great
work, ‘Schmerzlose Operationen,’ in 1896.” -
(3) “The discovery by Schleich (1888) that the thorough edemati-
zation of the tissues with standard isotonic solutions of Sodium chlorid
(o.2 per cent., Schleich; o.8 per cent., Heinze) at a low temperature
is in itself, as a process, an anesthetic agent. The experimental
PRINCIPLES OF TECHNIC I5I
evidence on this point began with the observations of Potain (1869),
Dieulafoy (1870), Lebroue (1870), and with Liebreich's researches on
the anesthetic properties of pure water. Halsted independently
Called attention to the same property of distilled water when infil-
trated into the derm, and also called attention to the efficacy of very
dilute Solutions of cocain as early as 1884. While saline infiltration
is not to be ranked as a surgically practical anesthetic, it is a most
powerful adjuvant to local anesthesia by increasing the effectiveness
of extremely dilute solutions of cocain in many ways that will be
referred to later.
(4) “The very important discovery made by Dr. J. Leonard Corn-
ing, of New York (1885), that the action of cocain can be indefinitely
prolonged as long as the circulation of the anesthetized area is arrested
by elastic constriction or other mechanical devices. This is Corning's
great discovery, undoubtedly the most important of his many original
suggestions, unless it be his discovery of the spinal subarachnoid
method of cocainization, in which his name will always be coupled
with that of Bier. The value of circulation stasis in prolonging and
intensifying the effect of cocainization occurred separately to Mayo
Robson, of Leeds, in 1886, Chandelux, of Lyons, 1885, and to Kummer,
of Geneva, 1889, but it is Corning who first suggested and popularized
it by his numerous practical demonstrations and contributions on the
subject.” -
(5) “The discovery that the infiltration of the sectional area of a
nerve-trunk in any part of its course with cocain or similar analgesics
is followed by a sensory paralysis of its entire peripheral distribution,
thus causing a complete anesthesia of all the parts that it supplies.
The infiltration of the nerves in this manner immediately “blocks'
the way to all afferent or sensorial impressions up to the point where the
injection or “blockade' exists. This procedure is equivalent to a com-
plete section of all the centripetal fibers of the nerve, only that the
effects are transitory as long as the circulation is not controlled.
This discovery, which is now recognized as a law in cocain technic,
is the foundation of the regional, as distinguished from the purely
local, methods of anesthesia. The first demonstration of its surgical
value we owe to Hall and Halsted’s clinical experiments in 1884,
undertaken almost immediately after Koller's announcement. It
was also demonstrated by Barrenechea, of Santiago, Chili, 1885; and
to some extent recognized, but not utilized, as we now understand it,
by J. Leonard Corning in 1885. It was more fully established as a
physiologic fact by U. Mosso (1886) and by François Franck (1892).
I52 LOCAL ANESTHESIA
“In German clinics it was probably first practised by Kochs in
1886, who was inspired by the researches of Mosso (1886) and Fein-
berg (1885), but it was popularized by Oberst, of Halle (1886), and his
pupils, who still refer to it as “Oberst's' method, and by Braun, of
Leipsic, a little later. Up to 1897 the principle was utilized only in an
indirect manner, i. e., by paraneural Subcutaneous injections and in
small operations. The application of this principle by direct injec-
tion into the nerves exposed by dissection was first made systematic-
ally by Dr. George W. Crile, of Cleveland, Ohio, who amputated a leg
painlessly after injecting the sciatic and anterior crural nerves on May
18, 1897, and by myself (Matas), independently (January, 1898),
in amputating the hand, after a preliminary cocainization of the
ulnar, median, and musculospiral nerves at the bend of the elbow.
The same principle was most admirably utilized by Dr. Cushing and
others in Dr. Halsted's clinic (Johns Hopkins Hospital) about the
same time (1907) for the radical cure of inguinal hernia. Dr. Young,
of the same institution, had also previously utilized this method in
securing anesthesia of the thigh for Thiersch grafting, which he did
by injecting the external cutaneous nerve under Poupart's ligament.”
(6) “The greater appreciation in recent years of the physiologic
fact that all the tissues and organs of the body, with the notable
exception of the papillary layer of the skin and the nerves, are, in
normal conditions, practically devoid of sensibility, and that if the
sensation of the derm and of the nerves that supply a given region
is subdued by an artificial anesthetic, the sensibility of the tissues can
be practically disregarded from the operative point of view. On
the other hand, the importance of psychic pain in the course of opera-
tions is not to be underestimated; and, as this cannot be controlled
by purely local anesthetic agents, it remains a serious obstacle, which
in major Surgery frequently compels a recourse to general or cerebral
anesthetics in spite of the total abolition of sensation in the field of
operation. The evidence on this point can be traced to numerous
and even ancient sources, but its great significance in the practice of
local anesthesia has been most forcibly presented by Dr. O. Bloch, of.
Copenhagen. (See ‘Bibliotek for Laeger,’ Copenhagen, 1898; ‘Re-
vue de Chir.,’ Paris, January Io, 1900; also H. Lilienthal, ‘Ann.
of Surg.,’ 1898, vol. xxvii.
“As a result of the practical applications of the principles embodied
in these discoveries or generalizations, the technic of local and regional
anesthesia has been gradually evolved into a method, or a variety
of methods, which for efficiency and safety far outstrip the most
PRINCIPLES OF TECHNIC I53
Sanguine expectations of the early advocates of local anesthesia. Not
only all the exigencies of minor surgery are met with success by the
new methods, but they are applicable with still greater force in a con-
stantly increasing number of grave, critical, and major conditions
which, a few years ago, would have been regarded as absolutely im-
practicable without the aid of general anesthetics.
“Before proceeding to consider the field of application of the new
technic, and the advantages that can be gained by its more frequent
and Systematic application in general surgical practice, let us first
define and classify these methods in order that their indications and
limitations may be the better understood.”
CLASSIFICATION OF THE METHODS OF LOCAL AND REGIONAL
ANESTHESIA IN WHICH COCAIN AND THE OTHER ALLIED
ANALGESIC DRUGS ARE UTILIZED AS THE ACTIVE AGENTS
“It should be first clearly understood that the artificial anesthe-
sia of any given tissue or organ of the body is entirely dependent for
its production upon the suppression of all sensorial (irritant) im-
pressions made upon that region through the agency of the nervous
system. This suppression can be effected by: (1) Paralyzing the
peripheral nerve-endings or terminal organs of sensation, as in the
papillary layer of the skin; or (2) by “blocking’ or obstructing the
path of all sensorial impressions in the nerve-trunks, including the
Sensory roots in the spinal cord that connect the field of operation
with the sensorium.”
Before considering the different methods of local anesthesia, we
must bear in mind that it is an operative analgesia that is aimed at,
and not an anesthesia in the true meaning of this term; it is a paralysis
of the pain-conducting fibers, and not those which conduct purely
tactile sensations, consequently the patient is always able to feel the
contact of instruments, fingers, etc., in the operative area, but pain
is absent. True anesthesia can be secured, but it is necessary to use
much stronger solutions, as the tactile conducting nerve-fibers are
much more resistant to the influence of the weaker solutions; for this
purpose it is accordingly necessary to use solutions of from 2 to 5 per
cent. strength, which are clearly unnecessary for Surgical purposes
where a perfect analgesia can be secured by Solutions of from o.25
per cent. and often weaker.
“Schleich, who is the father of the infiltration method, was first
to call attention to the value of salt in preventing the pain produced
by plain water infiltration, and, while many of his conclusions have
I54 LOCAL ANESTHESIA
been more or less contradicted by the experimental studies of Custer,
Heinze, and Braun, the fact remains that his first appreciation of the
remarkable sensitiveness of the tissues to such weak dilution of cocain
as I: 20,000 revolutionized the technic of local anesthesia and gave
new impetus to this mode of practice. According to Schleich, the
edematization of the tissues with a salt Solution (o.2 per cent.) at a
lower temperature than the body heat is the essential condition
required for the production of local anesthesia. The Small quantity
of the analgesic drug that he adds to his solutions (#, Tw, Hºw of I per
cent. cocain) is simply intended, he claims, to suppress the abnor-
mal hyperesthesia of pathologic tissues. When dealing with nor-
mal tissues he believes that a plain o.2 per cent. Salt solution is suffi-
cient to anesthetize, provided the tissues are thoroughly edema-
tized. The modus operandi of the simple infiltration method, as
he admits, does not depend solely upon the injection of a hypotonic
salt solution; there are other factors which enter more powerfully
into the causation of the anesthesia. These are: (1) The ischemia
of the tissues and partial stasis caused by the great pressure exer-
cised by the injected fluid on the capillaries and blood-vessels; (2)
the compression of the terminal nerve elements themselves from the
same cause; (3) the lower temperature of the infiltrated area caused
by using cold solutions, or by cooling these after their injection into
the parts. These purely physical conditions are undoubtedly of great
importance in favoring and intensifying the action of the analgesic
drug, and upon the thoroughness with which they are brought to play
largely depends the success of the infiltration method as it is prac-
ticed by Schleich. That Schleich has underestimated the importance
of the paralyzing effects of the cocain which enters into the com-
position of his solution cannot be doubted. Heinze and Braun con-
tend, as a result of numerous experiments, that Schleich’s solutions
owe their entire analgesic effect to the cocain they contain, and my
personal experience has convinced me that if the cocain were ex-
cluded from them they would cease to be of value as practical surgical
anesthetics. On the other hand, we must recognize that without the
process of edematization the weak solutions of cocain which Schleich
has taught us to use so effectively would become practically worth-
less.
“From the preceding discussion, it is evident that there are two
efficient factors concerned in the production of infiltration anes-
thesia which must be clearly differentiated from one another. One
is the physical effect of the infiltration from pressure, differences of
PRINCIPLES OF TECHNIC I55
temperature, etc. (Schleich); the other is the chemical action of
the drug employed (cocain, etc.) to paralyze the sensitive structures.
According to the preponderance of the physical or the chemical fac-
tors we may classify the practice of local anesthesia by infiltration
into two distinct methods: (1) Schleich's method, with a very weak
cocain solution, which depends upon the infiltration itself as the
effective agent and lays the greatest possible stress upon its physical
action; and (2) the method of Corning, Reclus, and the earlier German
anesthetizers (Wölfler, Landerer, etc.), in which the tissues are in-
jected, layer by layer, with stronger solutions (1 to 4 per cent. cocain),
and which depends for its efficiency almost exclusively upon the diffu-
sion of the chemical analgesics dissolved in the solutions.
“The preference given in the selection of these methods will be
determined by certain conditions, which will be referred to in dealing
with the topographic application of the technic in the various regions
of the body. In a general way, Schleich's method of infiltration is
indicated in all operations in which the circulation cannot be con-
trolled and in which the major part of the infiltrating solution must
be allowed to remain in the tissues. In this, as in all other methods
of local anesthesia, it is most important to remember that the derm
proper, and especially its papillary layer, must be first edematized
by intracuticular infiltration before beginning the infiltration of the
deeper planes; the same rule applies to the mucous surfaces. This
is a sine qua non in local anesthesia which cannot be repeated too
often.”
The original solutions, as advocated by Schleich, are the following:
No. I No. 2 No. 3
Cocain mur. . . . . . . . O. 2 Cocain mur. . . . . . . O. I Cocain mur. . . . . . O.OI
NaCl. . . . . . . . . . . . . O. 2 NaCl. . . . . . . . . . . . . O. 2 NaCl. . . . . . . . . . . . O. 2
Morphin sulph. . . . . o.o.2 Morphin Sulph. . . . . o.o.2 Morphin Sulph. . . . o.oo5
Aquae destil... . . . . . Ioo. Aquae destil... . . . . IOO. Aquae destil... . . . . IOO.
Solution No. I was intended for the skin, sensitive and inflamed
tissues. -
Solution No. 2, for less sensitive tissues, such as the subcutaneous
planes.
Solution No. 3, for massive infiltration of the deeper tissues, which
possess very little sensibility.
The idea in the addition of morphin was that it exercised some
slight local anesthetic influence and exerted its constitutional effect
by the time the anesthesia was passing off, thus relieving the after-
I56 LOCAL ANESTHESIA
pain in the wound. The idea of depending upon the anesthetic in-
fluence of such weak solutions of NaCl is objected to, as mentioned
elsewhere in this book, and the addition of morphin to the anesthetic
solutions for its constitutional effect is inadvisable; our aim should
be rather to simplify the solution, and when morphin is to be used to
give a definite dose some time before operation, as we advocate in the
combination of morphin and Scopolamin.
Recently, Schleich has modified the formula of his solutions to
the extent of reducing the quantity of cocain in each one-half and
adding an equal quantity of alypin, otherwise the solutions are the
same as originally advocated.
While the admixture of different anesthetic salts in solution
should, according to Burgi's views (discussed in the chapter on Sco-
polamin-morphin Injections), exert a more decided influence than
when a total equivalent quantity of any one agent is used, as well as
retaining the good points of each, while being sufficiently weak in each
constituent to prevent any unpleasant results that may arise from
the use in too large quantities of that particular constituent. This
fact has recently been made use of by Schleich in combining alypin
with cocain in his solutions. The advantages in the use of novocain
are so great and its toxicity so low, permitting so much more of it to
be used, and the clinical results so entirely satisfactory that we have
not found it necessary to resort to any combinations, but, if such
were done, novocain would be used as one of the constituents.
Schleich is opposed to the use of adrenalin for general use, but
approved of it for the extraction of teeth and on mucous surfaces.
The views of Braun, Heinze, and other prominent advocates of
local anesthesia are opposed to those of Schleich in the use of solu-
tions of such low freezing-point, heterotonic solutions, claiming that
solutions of such low specific gravity injure the tissues, preferring to
depend exclusively upon the chemical influence of the solution rather
than upon any physical influence for their anesthesia, and conse-
quently utilize only normal salt solutions as their solvent medium.
On theoretic and physiologic grounds this would seem to be correct
(see chapter on Osmosis), but from a very extensive personal clinical
experience, extending over many years, and the accumulation of
thousands of cases throughout the Surgical world, it would appear
that these fears have not been borne out on clinical grounds. Our
own reasons for discarding the use of the Schleich solutions has been
due to the many advantages presented by the use of Some of the
newer anesthetics, notably novocain, which we will discuss later.
PRINCIPLES OF TECHNIC I57
Following the introduction of eucain, Braun advocated the fol-
lowing solution:
Eucain B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. 2
NaCl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.8
Aquae destil... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOO
to which adrenalin was added. This was a very serviceable solution,
and is discussed under Eucain.
Later Braun suggested the following solutions, which are those
recommended in his book on “Local Anesthesia”: e
Solution No. 1.
Cocain hydrochlorate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. I
or Novocain..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.25
Normal Salt Solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOO
Adrenalin Solution. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . (I : Iooo)
or Homorenon Solution (4 per cent.). . . . . . . . . . . . . . . 5 drops
Solution No. 2
Cocain hydrochlorate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. I
or Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.25
Normal Salt solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5o
Adrenalin Solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I : Iooo)
or Homorenon Solution (4 per cent.). . . . . . . . . . . . . . . 5 drops
Solution No. 2 diluted one-half with normal salt solution gives
Solution No. 1.
Solution No. 3
Cocain hydrochlorate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.O5
or Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. I
Normal salt solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IO.
Adrenalin Solution...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I : Iooo)
or Homorenon solution (4 per cent.). . . . . . . . . . . . . . . 5 drops
Solution No. 4
Cocain hydrochlorate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.O5
or Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O. I
Normal salt Solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.
Adrenalin Solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I : Iooo)
or Homorenon Solution (4 per cent.). . . . . . . . . . . . . . . 5 drops
Solution No. 4 diluted one-half with normal salt solution gives
solution No. 3.
Solution No. 1 is the one recommended for general use, while in
more sensitive or inflamed tissues solution No. 2 may be used. Solu-
tions No. 3 and No. 4 are intended for such purposes as nerve-block-
ing, or for use in highly inflamed or sensitive tissues, and for use in
special regions (nose, throat, teeth, etc.).
The above solutions serve an extensive range of usefulness, and
are found equal to the demands of any condition except the purely
I58 LOCAL ANESTHESIA
topical applications, as used in the eye, nose, and throat, and for such
special work. -
In selecting solutions for practical clinical purposes we have tried
to simplify to the minimum the number of solutions used, and have
found it advisable to reduce the content of sodium chlorid as advo-
cated in the Braun solutions, in this respect adopting a medium
between that recommended by Schleich and the Braun formula; in
this way securing a certain degree of purely physical action from the
infiltration, at the same time having the content of sodium chlorid
sufficiently high to prevent any possible objection being found to it
on purely physiologic grounds, and at the same time to forestall the
possibility, however remote, of any injury resulting in highly sensi-
tive tissues as the result of too pronounced imbibition by the tissue-
cells. Consequently, after an extensive trial in several hundred
major operations we suggest the following as used by us:
Solution No. 1
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.25 (+ per cent.)
Normal salt solution (one-half). . . . . . . . . . Ioo.o. (.45 per cent. NaCl)
The above solution is the one recommended for general use, and
in the great majority of cases will be found amply sufficient for all
purposes. It has been utilized by us for the performance of major
operations about the body generally, as well as in such highly sensi-
tive regions as the face and anus; it is amply sufficient for the skin,
and, owing to the mild toxicity of the novocain, can be used for
massive infiltration of the deeper parts as well; it is found equally
effective for the blocking of medium-sized nerves, even as large as
those of the brachial plexus, and can be used on the sciatic, but for
the latter, as well as occasionally for the former, Solution No. 2 may
be found more desirable.
Solution No. 2
This solution is intended for use in more sensitive parts, such
as the nose, throat, mouth (teeth), for intraneural injections (brachial
plexus, Sciatic), and for paraneural injections, about the branches of
the trigeminus, pudic, etc., when reaching these nerves in their deep
positions with long needles. The solution can be made in o.5 to 2
per cent. strength, according to the apparent needs of the particular
case, and is as follows:
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . o.5, 1 or 2 (; to 2 per cent.)
Normal salt solution (one-half)....... Ioo.o. (.45 per cent. NaCl)
PRINCIPLES OF TECHNIC I59
This solution will, however, be found rarely needed, except in
special fields of work, as above mentioned.
The advantages of novocain, and the reasons for discarding the
Schleich solutions which we had so long used, is the lessened toxicity
of novocain (one-fifth to one-seventh that of cocain), its perfect
toleration by the tissues, and its ability to stand thorough steriliza-
tion by heating, as it can be repeatedly boiled without suffering de-
terioration; these and other advantages mentioned in the discussion
of novocain place it, for the present at least, at the highest pinnacle of
success of the synthetic chemist’s art.
The probability of the discovery of an anesthetic agent absolutely
devoid of toxicity or irritating qualities would seem very unlikely;
however, later advances may be able to still further reduce the toxicity.
In the preparation of solutions for purely topical applications,
5, Io, 20 per cent. and stronger, it is inadvisable to add sodium chlorid;
the concentration of these solutions places their freezing-point con-
siderably above that of blood-serum (they are hypertonic).
Regarding the addition of adrenalin considerable care should be
exercised, as this is an agent not free from danger itself, and many
unpleasant symptoms arising during the course of an operation at-
tributed to the anesthetic agent are in reality due to the adrenalin.
It is well to estimate the total quantity of solution likely to be needed
for an operation, allowing slightly an excess, and to this total quan-
tity, which has been previously sterilized, add the adrenalin from a
Sterile bottle and with a sterile dropper, using not over Io drops to
a 3-ounce mixture, or 20 drops to a 4- or 6-ounce mixture, which will
be found amply sufficient for all ordinary uses; by confining one’s-
Self within these limits of safety no unpleasant symptoms will arise.
Additional precautions may be necessary in using adrenalin upon
those with very high blood-pressure and in patients suffering from
Graves’ disease, where the vascular system is very easily excited.
Aside from the unpleasant constitutional effects which adrenalin
may exercise at the time of its use, when used too strong it is likely
to be followed by pain in the wound, and its injudicious use in strong
Solution has been followed by gangrene.
It will often be found convenient for office use, and for those doing
a limited amount of surgery to procure the novocain in tablet form
of definite strength, with or without sodium chlorid and always
without adrenalin; these tablets are then added to the necessary
amount of water and the whole sterilized, when the adrenalin is then
added. -
I6o LOCAL ANESTHESIA
The disadvantage in the tablets already containing adrenalin is
that its keeping quality in this condition is very questionable unless
quite fresh, and more particularly as in the sterilizing process the
adrenalin is largely destroyed.
The idea of adding other agents, antiseptics, etc., to the solutions
is to be avoided, as these substances often exert a hemolytic in-
fluence or otherwise prove irritant to the tissues; the possible con-
tamination of the solutions by alkalis (so often used in the steriliza-
tion of instruments) is particularly to be avoided, being both destruc-
tive to the anesthetic agent and when sufficiently strong exerting
decided hemolytic influence. Notwithstanding this knowledge,
Bignon at one time claimed that cocain in alkaline Solution was more
effective than in other media, alkalinizing the solution with sodium
carbonate, making a milky-like mixture. Braun tested the efficiency
of such solutions, and found them inferior in duration, intensity, and
diffusion power to the ordinary method of preparation, which gives a
solution nearly neutral in reaction.
More recently 3 per cent. Solutions of sodium phosphate have been
recommended for use with novocain as a substitute for the sodium
chlorid usually employed; it was claimed for this combination that it
produced a more profound and prolonged anesthesia. After a rather
extended trial in our clinics we failed to note any advantages, and
have accordingly returned to NaCl. It may be said, however, that
the combination is well tolerated by the tissues as no unfavorable
reaction was noted, and the anesthesia, while good, had nothing to
commend it over the sodium chlorid solution.
The use of highly concentrated solution of cocain is so general
with Surgeon specialists, particularly in the nose and throat, that
a few remarks regarding the action of such solution may not prove
out of place here, and should be considered in connection with in-
formation given in the chapter on Osmosis. -
The employment of Such strong solutions as are sometimes used
is only possible in such highly vascular (high nutrition) tissues as
in the nose and throat and in superficial wounds, which heal largely
by granulation and can be kept freely irrigated; if used elsewhere, the
hydroscopic action of these solutions would so desiccate the tissue-
cells as to be likely to produce serious consequences (the injection
into the skin of a Io per cent. Solution of cocain is painful and leaves
behind an inflamed indurated area).
The views of the specialist on this point is so ably put forth by
PRINCIPLES OF TECHNIC I6I
Dr. John Leshure (“New York Med. Jour.” of February 6, 1909) that
I quote his arguments at length:
“The marked absorptive power possessed by mucous membranes
render them peculiarly susceptible to the action of drugs applied
directly to their surface.
“In the case of cocain used for the purpose of inducing local anes-
thesia a certain amount of absorption is desirable, that is, it is neces-
Sary that the drug should reach the level of the nerve-endings, but
it is undesirable that it should enter the large venous and lymphatic
radicles, which are placed at a deeper level, since, by way of these
vessels, general absorption takes place, and toxic symptoms of greater
or lesser degree are likely to occur.
“Both cocain and adrenalin have the power of contracting super-
ficial and deep vessels, but the degree and rapidity of this contrac-
tion appears to be proportionate to the strength of drug solution
used.
“This is particularly true of the deep vessels, and it is necessary
to apply strong Solution of cocain and adrenalin to contract these
deeper structures promptly, for the solutions are rapidly diluted by
the copious mucous secretions and osmosis through the vessel walls
can then take place readily. We wish to bring the drug to the vessel
wall, but not through it, and to influence the vasomotor fibers which
surround the vessel.
“Fluids of high density, such as the cocain solution to be men-
tioned, are not readily taken up by the blood-vessels, and by the
time they are sufficiently diluted to be so taken up the local cir-
culation has been blocked off by the drug.
“By a strong cocain-adrenalin solution is meant one made by dis-
solving I gram of cocain hydrochlorid (flaky crystals) in I c.c. of a
I: Tooo solution of adrenalin chlorid. This Solution contains about
55 per cent. of cocain by volume, and has a specific gravity of I.I.Io.
“The following table gives the specific gravity of Some Com-
monly used solutions of cocain:
2 per Cent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
= Sp. gr. I.OO4
4 per Cent. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . = sp. gr. I.Oo3
Io per Cent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = Sp. gr. I.O2O
20 per Cent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = Sp. gr. I.O4o
25 per Cent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = Sp. gr. I.O5o
55 per Cent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = sp. gr. I.I.Io
“Certain laws governing the absorption of aqueous drug solutions
are: (1) A fluid passes through a membrane with a rapidity inversely
11
I62 LOCAL ANESTHESIA
proportional to the density of the fluid. (2) The rate of absorption
varies directly with the fulness and density of the blood-vessels and
lymphatics. (3) The slower the movement of the blood and lymph-
streams the slower will be the rate of absorption of the fluid.
“These well recognized laws of physiology explain the local reten-
tion in the tissues of the strong cocain-adrenalin Solution and the
lasting anesthesia and ischemia following its use.
“As the specific gravity of blood-serum is from I.O25 to I.O.32,
reference to law (1) shows that other things being equal the strong
cocain solution, having a specific gravity of I.I.Io, will pass through
the mucous membrane of the nose slowly as compared with the
weaker solutions (4 to 20 per cent.).
“The sequence of events resulting from the application of the
strong cocain-adrenalin solution to the mucous membrane of the
nose seems to be as follows: -
“A prompt, powerful stimulus is transmitted to the vasoconstric-
tor fibers surrounding the more deeply placed arterioles. The latter
then strongly contract, slowing the local blood-stream. At the same
time the caliber of the venous and lymphatic radicles is narrowed,
and the proximal pressure having been reduced venous stasis occurs,
as is evidenced by the deep redness of the membrane.
“General absorption is thus blocked off, and, the membrane con-
tracting, the nerve-endings and nerve-trunks are brought nearer to
the periphery, and consequently more directly under the influence of
the local anesthetic.
“All this time the cocain solution is becoming less dense, being
diluted by the mucous membrane secretion, and a certain amount of
absorption is taking place into the nerve-trunks through the axis
cylinder, since this latter structure is non-medullated near its distal
end.
“Areas quite remote from the point of application often are com-
plained of by the patient as being anesthetic, e. g., the teeth. The
passage of the drug up the axis cylinder to a ganglion, distributing
fibers to neighboring regions, may explain this phenomenon. -
“It has been recently demonstrated that toxic substances may
reach the central nervous system by way of the axis cylinder, also
that absorption may take place at the nodes of Ranvier, there being
a defective insulation of the axis cylinder at these nodes.
“In operating nerve-trunks as well as nerve-endings are sure to
be wounded, and the former must be rendered absolutely anesthetic
to insure the patient immunity from pain.
PRINCIPLES OF TECHNIC I63
“The physiologic action of the strong cocain-adrenalin solution can
be practically demonstrated, so far as its effect upon the blood-
vessels is concerned, using tadpoles as the subjects of investigation.
“When from 30 to 35 mm. in length these animals have a thin,
membranous, lateral outgrowth from the caudal appendage. This
is highly vascular, and each half is supplied by branches from the
aorta and Central vein of the corresponding side, which pass down
the thick Central stem. The point of practical importance is that
there is no direct communication between the blood-vessels of the
two sides.
“It is possible, therefore, to compare the results obtained by
simultaneously applying drug solutions of different strength to
corresponding portions of the structure referred to, which resembles
in many respects a mucous membrane. The animal is first curarized
by placing it in a small dish, containing about 15 ounces of water, in
which I's gr. of curarin sulphate has been dissolved. In from fifteen
to twenty minutes the muscular system is paralyzed, and the tad-
pole will lie quietly upon the microscopic stage. The small vessels
can be satisfactorily studied with a two-thirds objective and a 1-inch
eye-piece. A mechanical stage contributes greatly to the ease of
examination. A small drop of the strong cocain-adrenalin solution
(55 per cent. Strength) is placed upon the membranous structure
near the tail of the tadpole, and a drop of the same size of a 4 per cent.
Solution of cocain in I: IOOO adrenalin is placed at a corresponding
point on the opposite side of the caudal appendage. Slowing of the
blood-stream and venous stasis occurs at a much earlier period on
the side with the first-named solution than on that treated with the
weaker solution. In about twenty seconds the circulation in the
smaller vessels has practically ceased. The tadpole, being a gill
breather at this stage of its existence, cannot be kept alive more than
five or six minutes out of water, but control tests made with un-
cocainized animals showed that death occurred as early in these
individuals as when cocain was used.
“The fact would seem to prove that general absorption could
hardly have taken place, since cocain is a powerful cardiac paralyzant,
and would have caused death promptly had it entered the general
circulation.”
The above from Leshure deserves careful consideration, and ex-
plains admirably the action of highly concentrated solution when
brought in contact with the tissues; such solutions are swabbed on
mucous surfaces, as the nose and throat, and are not intended to be
I64 LOCAL ANESTHESIA
injected into the tissues. Strong Solutions should never be used when
it is possible to accomplish the purpose with the weaker dilutions,
but if they must be used, as seems necessary in nose and throat work,
which in many ways is a distinct departure from the method of use
of local anesthetics for general Surgical purposes, then we must have
a rational explanation for the action of such solutions, founded on
sound physiologic grounds and amply borne out by clinical expe-
rience. Such an explanation, I believe, is given above.
The safe use of such strong solutions requires great skill, and is
acquired only after long practice and experience and is not to be
lightly undertaken by the novice. .
The idea of using other than watery solutions of the anesthetics
(as in oils) as has been advocated at various times, and on purely theo-
retic grounds might seem to have some claims, has been found upon
practical tests to be unsatisfactory and possessing many disadvantages.
Water solutions, which are taken up by both veins and lymphatics,
are absorbed comparatively rapidly, while oily solutions are ab-
sorbed exclusively by the lymphatics, which always act much slower,
besides the oil globules choke the lymphatics and further delay the
process; this prolonged retention in the tissues should intensify the
local effect of the anesthetic as well as permitting it to be almost
entirely exhausted locally, thus diminishing the likelihood of con-
stitutional effects.
These solutions have been tested by Braun and found impractical;
the oily solutions are unsatisfactory to use, diffuse very poorly, exert
a weaker anesthetic influence, and frequently prove irritating to the
tissue.
For the sterilization of cocain solutions, where it is desirable to
use this salt, the solution will stand heating almost to the boiling-
point, and will not suffer any appreciable loss of strength, but re-
peated heatings render them inert.
Mikulicz has suggested the following method: He dissolves a
definite quantity of cocain in alcohol, allows the alcohol to evaporate,
and dissolves the precipitate in sterile water or salt solution.
Solutions of cocain should not be kept for more than a few days
as it very rapidly deteriorates, but should be frequently made fresh.
THE ARMAMENTARIUM
It is not at all necessary to have a complicated outfit for the
application of the various methods of local anesthesia; all that is neces-
sary is to have a supply of suitable syringes, preferably two or more
PRINCIPLES OF TECHNIC I65
of each, so should one become defective or be broken the work is
not interrupted. The syringe should preferably be all glass, with
glass plungers, and have no washers; the needles should slip on the
ground ends; needles which screw on and require washers are objec-
tionable; the screwing on process takes time, the washers frequently
|- !" - '''''''
- --
-
Fig. 4.—This illustration is reduced to about one-third size: the large syringe is
the plain ground glass of the Luer or phylocogen (P. D. & Co.) type, Io c.c. size; the
small syringe is of the same type and is the ordinary hypodermic of 25 to 30 m. capacity
(P. D. & Co. Glaseptic). The illustrations are intended to show the absence of all washers
or threads upon syringe and needle; they both have the same size beveled glass tip to fit
the needles and each fits the large or small needle as occasion requires.
give trouble, leak, and are otherwise undesirable. The simplest outfit
compatible with efficiency is the best.
In selecting such syringes the best makes will be found the cheap-
est in the end; care should be exercised in selecting them to be sure
that the plungers work easily and do not jam; the points which fit
the needles should be tapering and not pointed too acutely, otherwise

166 LOCAL ANESTHESIA
the needle will not fit securely and may fly off under pressure from
the syringe; the needles should be as fine as compatible with efficiency.
The idea of needles which slip on and off readily without having to
- .5 - - .6 - .7 - .7
Length. . . . . . . . . 25 3o 35 Öo 8o
Fig. 5.-Assortment of needles (after Braun).
unscrew them is of decided practical value as well as facilitating the
refinements of technic. It is well in selecting syringes to have the
different sizes fit the same needles, as this interchangeability will
often be found of great practical advantage (Figs. 4 and 5).



PRINCIPLES OF TECHNIC I67
(1) The syringe is more readily and quickly filled when the needle is
off. When this process has to be frequently repeated much time is saved.
(2) Where several syringefuls are to be deposited in the same
position the needle is allowed to remain in situ in the tissues; simply
slip off the syringe, which is refilled and again attached, thus avoid-
ing the necessity of making repeated skin punctures, which is an un-
necessary trauma. This method is particularly of advantage in in-
filtrating the subcutaneous tissues, we will say, over a hernia; here
the long needle, after one puncture in the skin, is advanced in the
subcutaneous tissues, and several syringefuls deposited at different
points or diffused generally as may seem advisable. º
Two sizes of syringes are recommended, the small ordinary hypo-
dermic size and a fairly large syringe, which will hold at least Io c.c.
with long needles (about 3 inches); such syringes stand boiling well
and are otherwise surgically satisfactory. When through using a
syringe the plunger should always be removed, wiped, and kept out
of the barrel; if allowed to remain in the barrel, it may become jammed
and only be removed after much difficulty.
For massive infiltration, and where the use of large quantities
of solution are necessary, the Matas infiltration apparatus will be
found highly serviceable, as it permits the easy infiltration of large
areas within a few minutes.
Most of the more commonly used formulas (Schleich, Braun, etc.)
of the various local anesthetics can be obtained on the market in
convenient tablet form, which when dissolved in a stated quantity
of water will give the desired solution. These tablets are usually
sterilized and some contain adrenalin; this last ingredient is inadvis-
able in tablet form, as its keeping qualities are very poor.
More recently manufacturers have put upon the market Sterile
tablets in sterile containers consisting of novocain, NaCl, and the
synthetic adrenalins (notably suprarenin synthetic), which is the
best, in graded strength of novocain and suprarenin, but with a uni-
form strength of NaCl, so that their solution in sterile water yields
standard solutions.
The tablets are highly useful for office use and for the extem-
poraneous preparations of small quantities of Solution. The objec-
tion to tablets containing the animal extract adrenalin does not
hold good here, as the synthetic preparations have been proved to
possess greater keeping qualities, and, especially with suprarenin
synthetic, capable of a moderate amount of sterilization (boiling for
from three to five minutes).
I68 - LOCAL ANESTHESIA
The sterilization of these tablets can be depended upon when
obtained from reliable manufacturers, but it is impossible to keep
them sterile when the container is constantly being opened for the
removal of tablets. We consequently prefer for institution or hospi-
tal work to prepare our own solutions freshly sterilized, to which we
add just before use the desired quantity of adrenalin or suprarenin
synthetic as preferred. This method has been found more satis-
factory in major operations, where it is imperative to have an abso-
lutely sterile and dependable solution.
CLINICAL APPLICATION
In starting to anesthetize any area the first step should be the
production of intradermal anesthesia, and should be done with a
small syringe and fine needle. In highly sensitive individuals the
Fig. 6.-Formation of an intradermal wheal (Braun).
point of entrance of the needle may first be anesthetized with ethyl
chlorid, but this is ordinarily unnecessary; if the skin at the selected
point is first pinched up between the thumb and finger and held
firmly it lessens its sensibility; with a quick but light thrust the
needle is advanced beneath the epidermis. While making this ini-
tial stick the thumb should be on the plunger, so that at the moment
that the needle enters the skin the solution can be injected; in this
way this initial stick is often made without the patient's knowledge.
This injection must be intradermal and not subcutaneous; it
should develop a distinct wheal, which stands up from the surround-
ing surface like an urticarial wheal (Fig. 6). This anesthetic point


PRINCIPLES OF TECHNIC I69
should be regarded as a “station” from which the anesthesia is dis-
tributed in the desired direction, either continuously in an intra-
/ 2 _2^ …” N
Fig. 8.
__
_2
/ -º-, *.
Fig. 9. -
Figs. 8, 9.-Intradermal infiltration (after Reclus) (Braun).
dermal line (Figs. 7, 8, and 9), or the long needle on the large syringe
can be advanced through the “station” to subcutaneous or deeper


17o LOCAL ANESTHESIA
parts and paraneural or other injections made as indicated (Figs. Io,
II, 12, 13). The proper method of anesthetizing the skin by intra-
- º --~
- ----------------------- --------- ----- - :-(2-0
- - - -------- --- - F=---------------------- --
--~ |-> *- - - - - - - - º
-
Fig. Io.—Subcutaneous infiltration from opposite points of entrance (Braun).
dermal injections was first taught us by Schleich and Reclus; for
this purpose the needle should be advanced in the deeper planes of
‘s `
Fig. II.-Methods of making subcutaneous injections (Braun).
the skin (the papillary layer contains the nerve-end organs); the
needle is inserted within the margins of the anesthetic wheal first
º 5.
º
% º
ſº
º% ź
º º
º º
º º
%º
º sº
% sº
º
%
%
º
%
º º
%-44%
rºl ſº º
%
º
º º º º
Ž
Fig. 12.-Schematic representation of cross-section through forearm and method of infil-
tration from four points (Braun).
made and progressively advanced, injecting the solutions as the
needle is being pushed forward, developing a ridge of infiltration


























PRINCIPLES OF TECHNIC I7 I
edema along the line of injection. When the needle is reintroduced,
this should always be done just within the margins of the last injec-
tion, otherwise each additional needle stick will be felt.
Fig. 13.-Method of producing a plane of anesthesia in subcutaneous or other tissues,
when injecting beneath a tumor, etc. (Braun).
The same plan is followed in anesthetizing a tract for aspiration or
exploratory puncture—we will say, for illustration of the pleural cav-
ity. This method of procedure is clearly shown in Fig. 14.
Fig. 14.—Method of infiltrating successive planes of tissue for exploratory puncture or
aspiration (Braun).
In making an injection over a wide area subcutaneously, or in the
deeper planes of tissues, one, two, or more points are first anesthetized
on the overlying skin, and the needle advanced in various directions,
continuously injecting as the needle is pushed to deeper depths, and
withdrawing the needle only sufficiently to direct its point in an-


I72 LOCAL ANESTHESIA
other direction, thus avoiding repeated unnecessary punctures of the
skin. This is illustrated schematically in Figs. 15 and 16.
Subcutaneous
tissue
Fig. 15.-Method of infiltrating several planes of tissue, including underlying bone from
two points of injection (Braun).
In making the injections they should not be too rapidly done, as
the sudden distention of the tissues may cause pain or rupture of
delicate parts.
Fig. 16.-Method of anesthetizing area of bone from two puncture points in surrounding
soft parts (Braun).
While it is generally advisable to precede any incision by an in-
tradermal infiltration along the proposed line, this is not invariably
necessary, as in cases where extensive dissections are to be under-



PRINCIPLES OF TECHNIC I73
taken the massive infiltration of the subcutaneous tissues reach and
anesthetize the nerves in their course to the skin, an indirect method
of anesthesia.
COLD
The sedative influence of cold when used alone has already been
referred to. Here a brief mention will be made of its intensifying
effects upon the anesthetic solutions.
Experimentation led to the information that cold solutions ex-
erted a more pronounced effect than those used at body temperature,
but when injected cold they excited pain in proportion to the low-
ness of their temperature; it was accordingly recommended that they
be injected at ordinary temperature and the area then cooled; this
was done by packing it in ice or the use of sterile bags filled with ice;
this refrigeration of the injected area was practised some years ago,
but is now rarely ever employed. Ethyl chlorid spray was also used
upon the surface to produce this refrigeration. To favor the diffusion
of the anesthetic solutions they were often injected warm and the
cold later added to intensify the effect.
The injection of solutions at temperature noticeably above or
below that of the body always excites pain, while the injection of such
solutions as are advocated in this volume at body or room tempera-
ture, at which point they should always be used, is absolutely devoid
of any appreciable sensation.
REGIONAL ANESTHESIA
Regional methods of anesthesia include all those methods which
control sensation of a peripheral part or area of distribution of any
nerve or plexus of nerves, or of any artery by proximal injections into
the trunk of the nerve or lumen of the vessel some distance from
the peripheral distributions. The same results are obtained by Bier's
intravenous anesthesia, and, in a broader sense, by spinal analgesia.
The following is a classification of regional methods:
Paraneural, injections made in contact with a nerve.
Intraneural, injections made within a nerve.
Spinal analgesia (including epidural injections of Cathelin).
Intravenous anesthesia (Bier).
Intra-arterial anesthesia.
Hackenbruch regional anesthesia, by circumferential injections.
By these methods the operator is often able to demonstrate the
high state of perfection to which purely local methods of anesthesia
have been developed. These procedures may be divided into the
I74 LOCAL ANESTHESIA
paraneural (indirect) and intraneural (direct) methods. Spinal anal-
gesia is also a regional method, which is discussed under a separate
heading.
A paraneural injection is made by inserting a needle into the tis-
sues to the known position of a nerve-trunk and there making the
injection; the solution surrounding the nerve-trunk envelops it in
an anesthetic atmosphere, which gradually diffuses itself into the nerve-
tissue. Obviously, an injection thus made should be of larger quantity
and greater strength than when made directly into the substance
of the nerve, as in the intraneural method; when such an injection
is accurately made, and the solution deposited in close contact with
a nerve-trunk, time being allowed for thorough diffusion, anesthesia
of the entire nerve distribution will result. This method is clearly
open to objections, as many errors are likely to result, as in cases
where the injection has not been accurately placed no anesthesia will
result; also it is possible to injure other structures or to make the in-
jection into a vessel. This method may often be regarded as unsur-
gical, and is hardly to be recommended where more exact methods
can be employed; however, it may be necessary under certain ana-
tomic conditions, as when blocking the branches of the trigeminus
at their exit from the skull or the branches of the pudic nerve near
the base of the tuberosity ischium. In making the injections in the
above cases, and elsewhere in positions where large veins may be
encountered, it is advisable never to make the injection when the
point of the needle is stationary, but always when it is being ad-
vanced or withdrawn, or after the exact position has been reached
by the point of the needle slight aspiration on the syringe can be
resorted to determine if a vein has been entered before making the
injection.
In such cases the injection of the solution into a vein is more to
be avoided than its introduction into an artery; the puncture of either
vessel by a fine needle is not in itself of any consequence, as no hemor-
rhage is likely to occur from such a small puncture, and we purposely
make them at times in intra-arterial anesthesia, where we wish to
anesthetize the area of distribution of a particular artery and use the
arterial blood as a means of distributing the solution to the tissues,
but in making the injection into a vein the concentrated solution is
carried at once into the general circulation and may reach the higher
nerve-centers in such quantity as to produce serious toxic results. We
must remember that the intravenous administration of cocain is the
most toxic; the toxicity of any injection of cocain depends upon the
PRINCIPLES OF TECHNIC I75
concentration of the Solution and the amount reaching the circulation
at any one time, and here we would have the maximum action.
While the intra-arterial injection is to be avoided as an accidental
occurrence, it is never as toxic as the intravenous administration, as
the Solution has first to travel through the ultimate distribution
of the artery, the capillaries, and which, if adrenalin is used, are com-
pletely occluded together with the arterioles leading to them by the
first contact of the adrenalin; as this response to adrenalin is imme-
diate, the Solution is thus retained for some time in contact with the
tissues and its action largely reduced before it is finally carried by
the return circulation to the heart. In the case of a vein, if of any
size, this action of adrenalin is insufficient to occlude it.
The intraneural (direct method) is more accurate, and decidedly
to be preferred whenever possible. It is applicable to any large nerve-
trunks, brachial (above the clavicle), ulna, median, and musculo-
spiral at the bend of the elbow, or at any other accessible points
along their course, also the sciatic and its divisions in the thigh and
leg. This method was first perfected by Cushing, Crile, and Matas;
as it is discussed in detail in the surgery of the extremities it will not
be repeated here. This method is also utilized in the course of any
operation whenever nerves are encountered, as in herniotomies,
thoracotomies, etc.
The method of making the intraneural injection is of importance;
the nerve should not be pinched up by forceps or other instruments,
as any such manipulations cause pain referred to its peripheral dis-
tribution, and may be sufficiently severe to make the patient cry out
or lose confidence in the promise of a painless operation; the injec-
tion should be made with the nerve lying in its bed, by inserting a
fine needle in the long axis of the nerve, first within its sheath, which
is edematized; the needle is then gently advanced between the differ-
ent nerve-bundles and the infiltration continued until the nerve
presents a fusiform swelling at this point, which may require from
5 to 15 minims of solution.
Complete anesthesia of its entire distribution usually results in
from five to ten minutes, but may exceptionally be delayed to twenty
minutes or longer. After making the injection the wound made to
expose the nerve should not be immediately closed, but loosely ap-
proximated by Stitches and protected by dressings, as it may occa-
sionally be necessary to make additional injections, particularly if
the operation is at all protracted.
Regional anesthesia may also be employed by the Schleich infil-
176 LOCAL ANESTHESIA
tration method by creating a circular ring of infiltration edema
around a peripheral part, such as a finger, and might, in exceptional
cases, be utilized higher up on the extremities when quite thin, and
in parts where the nerves which are encountered are not of such
E
|
ſ
S-2 Rºlittºº frn frºm Prº tº -
Fig. 17.-Apparatus for rapid massive infiltration anesthesia. Charging the cylinder
with air-pump (Matas).
size as cannot readily be penetrated in effective quantities by the
weak infiltrating fluid. The above method while simple, effective,
and often quickly executed, with suitable instruments, such as the
Matas infiltrator (Figs. 17 and 18), is not to be recommended when
regional methods or vein anesthesia can be applied.
Fig. 18.-Cylinder charged and inverted. The pumping outfit is detached when the
apparatus is in operation (Matas).
Conditions may, however, arise in which, through lack of facili-
ties or lack of technic, vein anesthesia cannot be carried out, and
amputation or other extensive operation on the peripheral part is


PRINCIPLES OF TECHNIC I77
necessary, and yet, owing to unhealthy conditions of the tissues,
nephritis, diabetes, etc., particularly when complicated by cardiac
or pulmonary disease, it is desirable to reduce the number of incisions
to a minimum; in such conditions, when the field of operation is in the
region of large nerves, a combined method of procedure may be
resorted to by first thoroughly edematizing the entire thickness of the
limb; the large nerve-trunks can then be sought for as the operation
progresses and blocked by an intraneural injection, slightly proximal
to the field by slightly stronger solutions than that used for the in-
filtration, when they can be then safely divided. This method, while
open to objections, may still be the method of choice under certain
extreme conditions; true, the edematization of the field may favor
- sº-Zone of cutaneous Ames/hesia.
Jurrounding field of operation
Skin
surface
z
Af A *z
22%23%, 22
7/7, , , , Z///Z.' zz %
---º %.4%—tº */ º, %
2.2%22%2%’,” ...º.º.2%. 22.2%; %X2%%
. . . .”.” !” ...??? 22: 24%
< * , , ,
& z
a z, Z
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A, w"
2% 2. 22> a'
2.’ ‘’’ 22, , , 2227
*
&
& 2 a. z e
e Zº * Z ~ * a
& * 2 * / . Z/ 2,2'22 ºz. . . . . . . . . . .22°, 2%. 2.
Kežve A ^2 * ~ * 22 - . . . . . . . 2, 2’’
Vertical section through tissues, taking in
margin of infiltrated area, showing method
of undermining field of operation with a
wall of anesthetic fluid.
Fig. 19.-Shows method of using Hackenbruch anesthesia around a tumor, carbuncle,
or other superficially situated lesion.
Suppuration in badly diseased or devitalized tissues, yet in cases of
amputation it is at a favorable site for drainage should suppuration
occur, and may offer the best and safest means of getting rid of an
offending member when gangrenous or otherwise diseased.
Hackenbruch recommended a method of regional anesthesia,
which he called circular anesthesia, by creating a wall of infiltration
edema around the region to be operated upon, and in this way inter-
rupts the conductivity of all nerves entering the area (Fig. 19). This
is a highly useful method, but applicable only to limited areas, for,
if too extensive, nerves may enter the area from below at points
which cannot readily be reached by the infiltrating solution. When
operating by this method, the infiltration of the entire area should












12
178 LOCAL ANESTHESIA
be completed before beginning to operate. This plan is particularly
applicable to cysts, carbuncles, boils, infected and inflamed areas,
where direct infiltration of the inflamed tissues are to be avoided;
it is also useful in the removal of epitheliomata and other malignant
disease, when superficially situated and of limited extent; this method
of operating, and that by the other regional methods, are the only
local anesthetic procedures which should be considered when deal-
ing with malignancy, as no injections should be made which ap-
proach the limits of the growths, as their infiltration may produce
a dissemination of the cancer cells into the surrounding tissues or
general circulation.
THE CONSTRICTOR
The important discovery made by Corning in 1885 that the ac-
tion of cocain can be indefinitely prolonged when the circulation of the
part is arrested by the use of constrictors or other mechanical devices
proved a decided advantage in all operations upon the peripheral
parts; since the advent of adrenalin, the therapeutic constrictor, this
advantage has been less apparent, but nevertheless of decided bene-
fit in many cases. Briefly, the advantages of constricting and arrest-
ing the circulation of the part permit an indefinite prolongation of
the anesthesia, and in addition by prolonging the retention of the
anesthetic agent in contact with the tissue-cells, with which it be-
comes largely fixed and their physiologic activity so reduced that
doses which may have been regarded as dangerous or toxic, used by
other methods, can often be safely used, or, by the intermittent
relaxation of the constrictor, permitted to enter the system gradually,
so that no untoward symptoms are produced. Obviously, too, the
immediate constriction of a peripheral part will arrest further absorp-
tion in cases of poisoning, and permit the system to recover before
more is allowed to enter the general circulation.
The intensifying effect of constriction upon the anesthetic in-
fluence of any agent used is further emphasized if the part is first
rendered ischemic; the absence of blood in the part with its diluting
and neutralizing influence removed, the drug can act exclusively upon
the tissue-cells and their nerve-endings.
The method of applying the constrictor, when used above the
anesthetized area on normally sensitive parts, is a point which should
receive careful attention; pressure from a constrictor carelessly applied
may be borne without complaint for a short time, but the continuous
pressure soon becomes intolerable, and the operation is often inter-
rupted by having to stop and readjust the constrictor. This is best
PRINCIPLES OF TECHNIC - I79
avoided by applying it only over well-padded parts, distributing
rolls over an area of 6 or 8 inches in width, and when possible within
the margin of the anesthetized area.
TECHNIC OF HANDLING WOUNDS IN GENERAL
In the surgical treatment of wounds, such as contused and lacer-
ated, incised, punctured, gunshot- or stab-wounds of the scalp, face,
and other parts of the body, requiring suture, incisions for freer
drainage, or painful manipulations necessary for cleansing, local or
regional methods of anesthesia may often be used to great advantage
in permitting the painless handling of the tissues and freedom of
work necessary to thoroughly cleanse or trim up ragged or crushed
edges or insert Sutures. When these wounds are of small extent and
Superficially situated, purely local methods of anesthesia will suffice;
where they are very extensive or involve the deeper parts or im-
portant structures, such as penetration or opening of a joint, division
of tendons, nerves, or other important structures, and even under
Some conditions in compound fractures or crushing or mangling of
the limbs, regional anesthesia may often be used to great advan-
tage, both by blocking the nerve-paths, thus preventing shock or
permitting painless manipulations necessary for the repair of the
damage.
Where purely local methods of anesthesia are used, as, for instance,
in a contused and lacerated wound of the scalp, the hair should
first be shaved from around the wound, protecting the wound mean-
while with a compress; this surrounding area then lightly cleansed,
and, if preferred, painted with 5 per cent. tincture of iodin. The
anesthesia is then carried out as indicated in Figs. 20 and 21, the
Small circles indicating the points in the skin at which stations of
anesthesia are established by intradermal infiltration; the dotted
arrows indicating the course and direction of a long needle, which is
to be inserted subcutaneously, making a rather free injection of solu-
tion as the needle is advanced, so as to create a wall of anesthesia
which will entirely embrace the wound; the depths of the subcutaneous
injections will of course depend upon the depth of the wound; when
situated upon the scalp the injection should be carried down to the
pericranium; when situated in other parts of the body, the injection
should be made according to the Hackenbruch method, by carrying
the long needle down into the tissues to below the depth of the wound,
but always keeping outside the wound in the surrounding unin-
jured tissues; the injections should be made more liberally in the
18o LOCAL ANESTHESIA
subcutaneous tissues, as it is here that the sensory nerves are more
freely distributed in their course to the overlying skin; the deeper
parts, being more sparsely supplied with Sensory nerves, will not
require such free injections unless along the course of recognized
nerve-paths.
After the anesthetizing procedure has been thoroughly carried
out, the compress may be removed from over the wound and the
entire area freely cleansed by further shaving if necessary, and the
wound washed out or irrigated and otherwise treated, as the indica-
tions require, with a freedom of manipulation so necessary for thor-
ough work that is rarely possible except in anesthetized tissues.
~!
* *
* * ~ -
-->
f
º
Figs. 20 and 21.-Method of surrounding scalp or other cutaneous wounds with zone
- of anesthesia (Braun).
Fig. 21 shows a contused and lacerated wound with undermined
edges; it is to be treated the same as Fig. 20; the radiating lines from
the area of laceration will require slitting up to permit access to and
drainage from the deeper parts. -
Poisoned wounds from snake-bites, rabid animals, or other dan-
gerous sources will require handling as expeditiously as possible,
which may not permit of the use of local anesthesia, although in the
hands of those skilled in its use but a very few minutes are required
for the infiltration, which of course should always be carried out by
the above-mentioned Hackenbruch plan, keeping well away from

PRINCIPLES OF TECHNIC I8I
the possible area of infection, and never by making the injections
directly into the wounds. Many such wounds occur in sur-
roundings where the necessary facilities and instruments are not at
hand for the practice of local anesthesia, brany other form, and the
indications may be sufficiently urgent to demand a heroic procedure
to remove or lessen the influence of the poison without any anesthetic.
However, many cases will present themselves where the indications
are not so urgent; here the application of a constrictor will prevent
any further absorption, and the few minutes delay necessary for the
anesthesia will be more than repaid by the greater facility and thor-
oughness with which incisions or cauterizations can be carried out,
and the great satisfaction on the part of the medical attendant that
he is not inflicting pain on a screaming and writhing but otherwise
willing patient.
Wounds of the palm of the hand or sole of the foot, but especially
the latter in hard-working people, where the tissues are dense and
leathery, are often very unsatisfactory for treatment by any method
of infiltration; the infiltration of such dense tissues is often very
difficult and frequently accompanied by a great deal of pain to the
patient; even though quite strong solutions are used. I have often
seen the barrel of the ordinary hypodermic syringe break under the
pressure necessary for infiltration in such cases. It is far simpler
and more satisfactory, both to physician and patient, to practice an
intra- or paraneural injection, as described in the chapter on Surgery
of the Extremities.
HEMOSTASIS AND CLOSURE OF WOUNDS
The closure of any operative wound made under local anes-
thesia where adrenalin is a constituent of the Solutions used calls
for increased care and thoroughness in securing all bleeding-points,
even the smallest ooze, for what appears at the time of no conse-
quence may, as the effects of the adrenalin subsides, increase and
give rise to hematoma, which may jeopardize the results of an other-
wise satisfactory operation. To prevent such consequences, hemo-
stasis should be perfect, and it is also advisable to anchor the over-
lying planes of tissue to the ones beneath during closure to obliterate
the possibilitity of any dead space. The skin Sutures should not
be drawn too tightly, but should allow of the escape of Serum from
the wound should any collect. A firm, Snug bandage, exerting a
moderate amount of pressure, is also a valuable adjunct as a final
step in the case.
I82 LOCAL ANESTHESIA
THE HISTORY OF THE HYPODERMIC SYRINGE
The invention of the hypodermic syringe, that wonderfully useful
instrument, is generally credited by most writers to Wood in 1855.
However, the idea seems to have originated with Monteggia (1813),
who suggested the use of a cannula for this purpose. But the real
credit for the invention of the modern hypodermic, as we know it
to-day, according to the investigations of Pfender (“Washington
Med. Ann.,” vol. x, No. 6), who reviewed the literature thoroughly,
seems undoubtedly to belong to F. Rynd, an Irish surgeon, who
introduced the instrument in 1845. Pravez in 1851 introduced a
cannula of capillary size, following out the idea of Monteggia, which
was used for injections. In 1885 Wood first wrote on the subject of
the Syringe, and popularized it through his numerous writings and
brilliant demonstrations, but the real discoverer seems undoubtedly
to have been Rynd.
The French manufacturers in 1862 introduced an excellent in-
strument which would compare favorably with those of to-day, but,
even with this hypodermic, it was recommended that its use be
preceded by the Richardson ether douche, as the ether spray was
then called. Rapid improvements in manufacture followed, until
we have the perfected instrument of to-day.
CHAPTER DK
THE USE OF MORPHIN AND SCOPOLAMIN AND COMBINED
METHODS OF ANESTHESIA
MORPHIN AND SCOPOLAMIN
IT is hard to determine exactly when morphin and other syner-
gistic drugs were first used as a preliminary or preparatory treat-
ment to operations under local anesthetics. The discovery of mor-
phin considerably antedates that of cocain, and its hypodermic use
began with the introduction of the hypodermic syringe by Rynd in
1845, when it was used extensively as an injection into the site of
pain for such affections as neuralgia, pleurodynia, arthritis, etc.,
with the idea then prevailing that it exercised a considerable local
as well as constitutional action. The prevalence of these ideas no
doubt largely influenced medical thought later when morphin was
combined with cocain in local anesthetic mixtures, such as in the
Schleich solutions. These views were found to be largely in error,
for morphin, while it does exert a certain limited local action, it is
necessary to use 4 per cent. Solutions to produce any decided local
analgesic effect, a concentration clearly beyond any possible consid-
eration; it is, therefore, more rational to give the morphin separately
and preceding the operations, rather than to include it in the anes-
thetic solution, for, if used in an effective strength in these solutions,
in many operations where an undetermined amount of Solution will
be used, as in very extensive infiltrations, a toxic amount of the
drug may be given. What is decidedly better is to administer a definite
dose of morphin separately and before the operation—besides the aim
should be to simplify rather than complicate the anesthetic solution;
it should accordingly contain no agent which is not of decided value
locally, either for their anesthetic action or vasoconstriction, as adren-
alin, or NaCl, used to make the solution more nearly isotonic with
the blood.
However, the discovery that the central analgesic effect of mor-
phin on the cortex and psychic centers greatly assist in preparing
183
I84 LOCAL ANESTHESIA
the mental attitude of the patient for the action of local anesthetics
has materially contributed to the success of local and regional anes-
thesia. -
This suggestion independently occurred to many operators simul-
taneously, but Ceci, of Genoa, has, since 1897, insisted upon the syste-
matic use of morphin as a preliminary to local anesthesia, and the value
of the Suggestion has been recognized in almost all clinics where local
anesthetics are most frequently resorted to. The advantages in the
use of morphin, in doses of # to # gr., given hypodermically from
One-half to one hour before any major operation under local anes-
thetics as a preparatory injection, are many and are quite apparent
to those who resort often to these measures. Here it may be well to
refer to the chapter on Pain, particularly the psychic control over
pain, to better understand the advantages of this procedure. The
mental state of attention and anticipation influences the acuteness
of painful impressions; it must, indeed, be a trying ordeal on nervous
patients to undergo an operation of any magnitude by purely local
means of anesthesia. This feeling of dread and anxiety, with all
the senses in a thoroughly active mind anticipating and waiting the
first touch of the knife when tactility may be interpreted as pain and
the strange surroundings of the operating-room are not those which
would restore tranquillity, may prove trying to the operator and is
certainly so to the patient.
Some individuals of placid or phlegmatic temperament, who
have confidence in the operator, are quite satisfied with his promise
that there will be no pain, but many others, nervous or high-strung
individuals, are not so fortunate temperamentally, and become rest-
less and uneasy, and will find one-half hour or an hour spent on the
operating table in itself quite a severe trial, although they actually
experience no pain, but are conscious of the operation being per-
formed.
With such patients it is highly desirable to substitute a more
placid, tranquil mental stage for that of anxiety and uneasiness; this
is best insured by the administration hypodermically of # to # gr.
of morphin, either alone or in combination with scopolamin, Hºw to
Tºp gr., about one hour before operation; this induces a drowsy,
pleasant state of mind, and the patient approaches the operating-
room in a quite cheerful attitude, in marked contrast to many not so
treated, who are fearful and trembling, and declare at the last minute
that they do not feel equal to the ordeal. (See chapter on Anoci-
association for effects of fear upon the central nervous system.)
METHODS OF ANESTHESIA 185
There are other advantages in this preliminary hypodermic,
as both morphin and Scopolamin congest the cerebrum. Cocain, in
exerting a toxic influence, is supposed to produce an anemia or vaso-
constriction centrally, the same as it does locally, as an initial phe-
nomenon in its toxic action; while morphin is not the ideal antagonist,
as discussed in the chapter on Toxicology, it nevertheless does seem
to exert a prophylactic influence in preventing the development of
toxic symptoms; this is particularly so in nervous excitable indi-
viduals, who are undoubtedly more likely to develop unpleasant symp-
toms, even if nothing more than a slight palor, nausea, or uneasiness.
These manifestations, as well as other unpleasant disturbances and
reflexes, are all less likely to occur following the preliminary hypo-
dermic. -
As spoken of elsewhere, when toxic symptoms arise it is due to
the use of an excess of the drug beyond that needed to produce com-
plete local anesthesia, the result of too strong solutions, poor technic,
or its injudicious use. Personally, I have never had any toxic symp-
toms to combat, but in highly susceptible individuals, with marked
idiosyncrasy, such disturbances may occur, and it is well to forestall
their development if possible. The effect of such a hypodermic is
quite lasting, six to eight hours, and eliminates the necessity of a post-
operative injection being needed for after-pains.
The idea of combining two such agents as morphin and Scopolamin,
while not syngergistic in the entire range of their action, are in So far
as they dull the mentality and produce a tranquil somnolent state;
morphin, however, acting more especially in its influence over pain,
while scopolamin is used entirely for its somnolent effect. This idea
of the combination of such narcotics as morphin and Scopolamin,
which are extensively used together, bear out Burgi's contention that
the sum of the combined action of two or more narcotics adminis-
tered simultaneously, or shortly after each other, produce a much
more powerful effect than when a total equivalent quantity of either
one narcotic had been administered alone. This increased action
is particularly marked when the two narcotics have different cell
receptors, and that a dose of any one drug acts much more markedly
when given in frequent small doses than when administered at once
in a single dose; this last part of his contention is, however, not of
value to us here.
Other advantages of the preliminary hypodermic are that it
seems to intensify and prolong the action of the local anesthetic
used, either by removing the psychic state favorable to the develop-
I86 LOCAL ANESTHESIA
ment of pain or by dulling the pain perception centers, enabling the
operator to succeed with a minimum amount of the anesthetic Solu-
tion. This last view is entirely in accord with Burgi's contention;
the morphin centrally is synergistic to the action of the cocain locally.
While advocating the single preliminary injection of the two agents
in medium-sized doses as desirable in nervous and excitable indi-
viduals, as a means of allaying this excitement and thus protecting
the patient against himself, we do not invariably make use of the
procedure except in operations of considerable magnitude, and never
use it as a means of anesthesia alone, and wish to very positively
condemn such a practice as highly dangerous and unsurgical, to say
the least.
The idea of using these two drugs for anesthesia alone or in com-
bination with cactin or other agents is fraught with the greatest risk
possible, and had its origin in the suggestion in 1900 by Schneiderlin
that they be used in large doses as a means of producing surgical anes-
thesia; this idea was founded on an erroneous conception that the two
drugs exerted a certain cardiac and respiratory antagonism while
being synergistic in their analgesic and hypnotic qualities; this,
however, was soon shown to be an error, and Wood in 1905 was able
to collect 2000 cases with 9 deaths, or I to 221—a frightful mortality—
and in 69 per cent. of the cases a general anesthetic was necessary
to complete the operation.
A few words regarding the action of Scopolamin may not prove
uninteresting. Scopolamin hydrobromid is claimed by some to be an
impure hyoscin hydrobromid; however, its action seems identical
with the latter drug. Its principal action is upon the cerebrum,
inducing sleep; it is also feebly depressant to the spinal cord, but it
exerts no influence as an analgesic.
The pulse-rate, while usually slightly lessened, is not markedly
affected. The respiration is depressed by large doses, but seems little
or not at all affected by medium doses, Tºro gr.; when death does
occur, which, however, is said to be extremely rare, with even very
large doses, it occurs as the result of asphyxia; 7% gr. have been in-
jected intravenously into a dog without destroying life.
The skin is usually quite moist following its action, the nose,
throat, and mouth dry, and the pupils, as a rule, dilated.
A new narcotic, pantopon, introduced by Sahli, of Berne, in 1909, is
now occupying much attention owing to the therapeutic advantages
claimed for it. It consists essentially of a mixture of the combined
alkaloids of crude opium, said to exist in a definite stable Solution
METHODS OF ANESTHESIA 187
in the form of chlorids in a fairly constant proportion—viz., morphin,
narcotin, codein, papaverin, narcein, thebein, hydrocotarnin, codamin,
laudanin, laudanidin, laudanoein, miconidin, papaveramin, protopin,
lanthopin, cryptopin, gascopin, oxynarcodin, xanthalin, and tritopin.
It is obtained as a yellowish-brown amorphous powder resembling
powdered opium, easily soluble in water, less so in alcohol. Panto-
pon is particularly recommended for administration before general
anesthetics, but it may be, if it fulfils the claims made for it, that it
may largely supersede morphin in a more general use; further, the use
of such multiple combinations of alkaloids as exist in pantopon bear
out Burgi's contention.
The dose of pantopon is given as slightly greater than that of
morphin, o.3 grain of pantopon equalling o.25 grain of morphin. The
anodyne effect is very marked, the pulse is slow and regular, the
respirations are quiet, regular, and deeper than after morphin, and
their frequency but slightly less than normal; in other respects its
action is very similar to that of morphin. Due to its very slight action
upon the respiratory frequency and depth, it has been particularly
recommended for administration before general anesthetics, but these
advantages are not of much value to us here. Other advantages
claimed for this drug are that the after-nausea and other unpleasant
disturbances are much less than after morphin.
COMBINED METHODS OF ANESTHESIA
While in the preceding remarks the use of morphin and scopol-
amin are not used for their anesthetic effect, they undoubtedly exert
Some influence in that direction by acting as cerebral anodynes, and
may often contribute, when in combination with local anesthetics
and the light superficial use of general anesthetics, to accomplish safely
a delicate surgical procedure.
“The discovery of the fact that by utilizing the anesthetic proper-
ties of cocain and other local anesthetics (including ethyl chlorid,
Bloch) with morphin, a preliminary stage of diminished sensibility
is produced, which is also most favorable to the action of general
anesthesia, so that an important group of major operations which
cannot be undertaken with local anesthesia alone, and in which the
Condition of the patient contra-indicates chloroform or ether, can be
painlessly performed with the aid of a very superficial, intermittent,
and purely cortical anesthesia (Morphin-cocain-ether Anesthesia).”
In this method the essential point is also to subdue the sensi-
bility of the skin as a preliminary; after this is accomplished very
I88 LOCAL ANESTHESIA
little general anesthetic will be required to complete the operative
work in the deeper tissues. No Saturation with ether, as a rule, will
be needed, and in this way the dangerous effects of the drug will be
avoided or will be reduced to a remarkably safe minimum. (See O.
Bloch, loc. cit.; Schleich, loc. cit., and H. Cushing, “Annals of Surg.,”
January, 1900). (Matas.)
Such conditions may arise in the badly septic or marasmic patient
—nephritic, diabetic, endocarditic, and other constitutional states—
where surgical relief seems imperative yet inadvisable by any single
means alone, as when such patients are suffering from appendicitis
with an adherent, embedded, or retrocecal appendix, or from a chole-
cystitis with a difficultly accessible gall-bladder, ectopic gestation,
etC. -
In such cases the combination of all methods may prove ad-
visable, making use of a morphin-Scopolamin, cocain-ether, or chloro-
form anesthesia. If the field of operation is so situated that spinal
anesthesia will prove effective this should, of course, be given con-
sideration, but often this will not be advisable or suited to the case;
under such conditions, with the patient quieted with a preliminary
hypodermic, the peripheral or easily accessible parts are anesthetized
by local or regional measures, advancing as far as possible by these
means to the seat of trouble, when a few whiffs of a general anes-
thetic, sufficient only for a purely cortical anesthesia, inducing at most
a subconscious state, in which pain alone is arrested but memory and
the other senses are often retained, and thus enable the operator to
execute the deeper parts of the work without pain, the patient al-
lowed to recover as soon as this is accomplished, when the closing
steps of the operation are completed by local measures. While
conditions justifying combinations of this kind do not often occur,
they are occasionally met with, and can often be more safely handled
by combined measures than by any single method used alone.
On the other hand, one may often undertake intra-abdominal
operations by local anesthesia, and, once within the abdomen, en-
counter unexpected difficulties by meeting more extensive pathology
or complicated conditions not anticipated, and be forced to resort
to a general anesthetic to perform the more difficult parts of the
operation, withdrawing the general anesthetic when this is completed.
In the above connection we may call attention to the intra-
abdominal action of urea and quinin hydrochlorid, as spoken of by
Dr. Thibault in the chapter on Quinin, but which we have not so far
had occasion to use in this way. -
METHODS OF ANESTHESIA 189
Another class of patients where combined methods of anesthesia
may prove highly useful is in operation upon the neurotic, emotional,
or highly sensitive individual, where, owing to contra-indications, it
is inadvisable to operate by general anesthesia. Resort can often be
had to purely cortical anesthesia while performing the operation pain-
lessly under local methods, thus preventing both the psychic in-
fluences in their production of shock as well as all reflexes from the
field of operation.
Psychic impressions bear no Small part in the production of shock,
and reflexes thus excited from the brain may affect the vital centers
just as seriously as the effects of trauma at the periphery.
Crile has always insisted on this element in the production of
shock, and the published results of his experiments show clearly that
definite demonstrable changes occur in the cells of the brain as the
result of fear. He has amply shown that trauma, anemia, infection,
and fear produce not only very definite symptoms, but that singly or
in combination may damage the brain-cells, and so influence the im-
mediate results of Surgical operations. (See chapter on Anoci-associa-
tion.)
The idea and advantages of combining spinal analgesia with a
light superficial ether narcosis, sufficient to prevent the shock from
psychic impressions, has been advocated by some writers, and the
advantages of such combinations here may at times be decided.
Combined methods of anesthesia may often be advantageously
utilized by the surgeon specialist, as in operations upon children or
highly nervous patients for affections about the nose and throat;
here all that is necessary is to keep the patient asleep, using a very
superficial anesthesia, which can often be administered in a semi-
recumbent position, ether being preferred; the anesthesia of the part
is secured in the usual way by the local use of cocain; as the field of
operation is blocked by the use of the local anesthetic, shock is often
less than when operating by general anesthesia alone.
The rationality for the use of combinations such as morphin-
scopolamin or cocain-ether is amply explained by Burgi's contention,
and if this contention is correct, and it seems to have been amply
demonstrated, we can readily understand how the skilful use of small
quantities of each agent, each too small to exert any possible in-
jurious actions alone, often enables one to accomplish absolutely
painlessly and safely operations of considerable magnitude.
As just stated, it will probably be seen, on further thought,
that all four agents are actually more synergistic than might ap-
I90 LOCAL ANESTHESIA
pear. It will be readily conceded that morphin, Scopolamin, and ether
(or chloroform) enhance the central action of each other; but, how
about cocain? This has been amply demonstrated to exert a well-
marked central action as well as local. For a confirmation of this
statement we refer to the abdominal experiments of Kast and Melt-
zer, spoken of in the opening part of the chapter on Abdominal
Surgery; also to general anesthesia by cocain, as proved by Harri-
son’s and Ritter's experiments, and cited under General Anesthesia
with Cocain.
CHAPTER X
INDICATIONS, CONTRA-INDICATIONS, AND SHOCK
INDICATIONS AND CONTRA-INDICATIONS
IT has been said that the advantages of operation under local
anesthesia are entirely with the patient; this is so in so far as life is
concerned, but the surgeon too often shares in the benefits that arise
from this method of operation, his aim being always to relieve suffer-
ing and save the life of the patient; the reduction of his mortality
by safely tiding an operative case through the many dangers which
threaten must, indeed, be a source of great satisfaction to the conscien-
tious operator. The special advantages offered to the comfort of the
patient are the absence of the disturbances incident to general anes-
thesia. The fear of general anesthesia entertained by many people,
especially if they have had one experience and suffered much from
postoperative nausea, will often deter them from subsequent opera-
tive treatment unless imperative.
The distinct advantages in addition to those of relief from fear
are :
It is unnecessary to starve the patient beforehand. The alimen-
tary canal should, however, be well emptied by a suitable cathartic,
and a light nutritious meal given at the regular meal time preceding
the operation. All patients stand local anesthetics better when fed
beforehand, and it is a distinct advantage in preventing weakness or
shock in debilitated subjects.
There is no postanesthetic disturbance to the alimentary canal,
which is often so trying to both patient and physician, such as the
vomiting and straining accompanying the act, causing both pain and
frequently, when severe or prolonged, jeopardizing the results of the
work when this has been about the face, mouth, or abdominal walls.
The possibility of dilatation of the stomach and intestinal paresis
or tympanites is eliminated.
The regular postoperative nourishment is not interfered with;
this is of great importance in weakened individuals, and permits a
more rapid recovery and convalescence from the operative proce-
dure. Many weakened subjects may survive the operation, but die
191
I92 LOCAL ANESTHESIA
from exhaustion due to interruption of nutrition as the result of a dis-
turbed alimentary canal.
The pain in the back so many suffer from after prolonged general
anesthesia, due to complete relaxation of all ligamentous supports
to the vertebral column, permitting Sagging of the lumbar curve
with necessary strain, is avoided.
General anesthesia is particularly dangerous to the cachectic,
the feeble, aged, arteriosclerotic, in those suffering from advanced
cardiac, pulmonary, renal and hepatic disease, and in alcoholics,
as well as in many other conditions, such as shock, to be mentioned
later. - -
Chloroform is particularly dangerous in all cases of Septic infec-
tion. It may be argued that in some of the above-mentioned condi-
tions local anesthesia may present certain dangers; this may be true
in some few cases, but the danger is always less than that of general
anesthesia. -
Local anesthesia seems actually contra-indicated in very few condi-
tions, among which may be mentioned children, epileptics, highly
nervous or neurotic subjects, and exceptionally in other conditions
there are actually very few pathologic conditions in which local anes-
thesia is not safer than general. .
The additional trauma suffered by the tissues, due to the infiltra-
tions, might in Some few cases of low vitality be regarded as a disad-
vantage, but it is in just such cases of low vitality that general anes-
thesia is more dangerous.
SHOCK
Shock when severe is a condition in which general anesthesia is
contra-indicated; the administration of a general anesthetic does not
necessarily relieve the reflexes to the higher centers, and when this
condition is marked may prove highly dangerous, and should not be
used when it is possible to employ local, regional, or even spinal anes-
thesia, which block the afferent nerve-paths and prevent further im-
pressions being recorded at the higher centers.
Dr. Crile's studies, demonstrations, and brilliant presentation of
this subject has elucidated many points previously but imperfectly
understood. In the Brit. Med. Jour. of September 17, 1910, on the
“Prevention and Treatment of Shock,” he writes as follows:
“It is well also to bear in mind that in inhalation anesthesia
only a part of the brain is asleep. Complete anesthesia of the brain
produces suspended animation or death. The medulla at least is but
INDICATIONS, CONTRA-INDICATIONS, AND SHOCK I93
little affected, and the response of the unanesthetized portion of the
brain is constantly observed in the course of operations; for example,
the altered rate and rhythm of the pulse and respiration, the change in
the vasomotor tone, as indicated by the fluctuation in the blood-
pressure, the contraction of muscles, and, under light anesthesia,
purposeless movements of the body, all show that a large portion of
the brain is either partially or not at all anesthetized. These sub-
conscious phenomena represent the discharge of nervous energy in
response to mechanical stimulation of the nociceptors, and are vain,
subconscious efforts of defense or escape. The greater such sub-
conscious action, the greater the shock. In bad risks the subconscious
response should, if possible, be wholly excluded by the combination
of local with general anesthesia, the local anesthesia physically block-
ing the afferent impulses, thus sequestering the brain from harmful
impulses.”
In operations upon the larynx the reflex inhibitory impulses
should be prevented by the local application of cocain.
In all operations where the impressions from the field of operation
may favor the development of shock local anesthesia should be com-
bined with general; this also lessens the necessity of profound general
anesthesia. Also spoken of under the heading of Combined Methods
of Anesthesia.
Whenever in the course of an operation large nerve-trunks are
to be divided, and the possible effects of shock are to be avoided, as in
the division of the sciatic branches of the brachial plexus, etc., the
nerves should be first injected with a cocain solution before division.
Dr. Crile in his operations for goiter, which are usually in a class
of patients easily shocked, almost always combines local and general
anesthesia. For a further consideration of the effects of shock and the
use of local anesthetics in its prevention, see chapter on Anoci-aSSO-
ciation.
13
CHAPTER XI
ANOCI-ASSOCIATION
A NEw interest and impetus has been given to local anesthesia
by the recent work of Crile on “Anoci-association.” This principle,
founded on sound physiologic grounds and well tested clinically,
marks the beginning of a new era in Surgery. Crile's early work, as
a pioneer in local anesthesia, had done much to advance the art and
help place it upon a firm and scientific foundation, and now he shows
the way to new and hitherto unrecognized advantages in its use, either
alone or combined with general anesthetics.
His work in this line and the results which he has obtained admit
of no controversy.
Trauma, hemorrhage, and psychic influences are the three great
shock producers. The effects of trauma may be either conscious or
unconscious (as when under an anesthetic).
Crile compares the nerves, whether of special sense or common
sensation, to fuses, which when stimulated cause a release of energy
in the magazine (the brain-cells).
In inhalation anesthesia only a part of the brain is asleep; if the
entire brain were anesthetised it would produce death. The purpose-
less movements of a patient under an anesthetic are efforts for defense
or escape, and represent so much discharge of energy. Muscular con-
tractions under operation, the quickened heart-beat, or disturbed
rhythm of respiration, all represent reflexes arising from the field
of operation and producing their impression on the brain-cells.
During fear or other psychic strain tremendous energy is given
off; if continued, leading to exhaustion and shock. We do not possess
a single anesthetic capable of protecting the brain during operation
from harmful stimuli or reflexes. General anesthetics prevent the
psychic stimuli; local anesthetics block the nerve-paths and prevent
traumatic reflexes; the combination furnishes the ideal.
In children and nervous individuals who enter the operating room
in fear and trembling the above combination is undoubtedly the best.
Too little attention has been paid in the past to these psychic influences
and the effect of trauma under anesthetics, and it is in preventing these
nocuous influences that much improvement can be attained in the
194
ANOCI-ASSOCIATION I95
future. In the stout and robust, who have energy to spare, this may
not be so apparent, but few of our patients are from this class; many
are already reduced by the condition which brings them to surgeons.
We too often see patients requiring weeks or months to regain their
health following an ordinary operation, their depression being out
of all apparent proportion to the operation and coincident confinement
in bed, or see the neurotic or neurasthenic made worse by the pro-
cedure which was intended to improve.
In these cases too little attention has been paid to, and no provi-
sions made for, the psychic strain and trauma under anesthetics, and
which persists from the incised and traumatised parts until healing
has taken place.
It is along these lines that improvement must come in our opera-
tive surgery of the immediate future. Improvements will come in
our operative technic, but the fundamental principles underlying
the commonly performed operations of to-day are not likely to suffer
any radical change, at least with the present conception of surgical
principles. But improvements can come, and are within reach of us
all, for the operative handling of our cases.
Children and highly nervous individuals should not be operated
on by purely local methods alone, but by combinations of local with
general, and here the general anesthetic need not be pushed to the
point of profound narcosis, but only sufficiently deep to prevent psychic
and cortical reflexes. By this plan we will have accomplished the
ideal for these patients by removing the dangers of profound narcosis,
and favor a pleasanter and more rapid and complete recovery by re-
moving all elements of shock.
In the average individuals who make up the great majority of
our patients, when suffering with conditions favorable for opera-
tion under purely local or regional methods of anesthesia, the general
anesthetic can be entirely dispensed with, and the psychic influences
controlled by a preliminary hypodermic of morphin, ; grain, with
scopolamin, tº grain; this produces a somnolent, indifferent frame
of mind quite favorable for any operative undertaking; when, if our
technic is perfect and no pain inflicted, we have accomplished the
ideal for this class of patients which make up our great majority,
and no major operation should be performed under local anesthesia
without this preliminary hypodermic.
Dr. Crile, in employing his anoci principle, begins the injection
of the local anesthetic after the patient is unconscious from the gen-
eral anesthetic; he prefers to use o.5 per cent. quinin and urea for
I96 LOCAL ANESTHESIA
blocking purposes, and the technic is the same as if the operation
was to be performed under purely local methods alone, infiltrating
or blocking all regions, consequently the methods described in this
book can be followed. We, however, feel some hesitation in using
quinin and urea too extensively and in all tissues for this purpose;
while it does produce a lasting analgesia for several days to a week, its
objectionable quality of often producing massive fibrinous exudates
in the infiltrated area, with an occasional tendency to suppuration,
must not be lost sight of, as pointed out in the chapter dealing with
I 2
Fig. 22.-Anoci-association diagram: I, Auditory, visual, olfactory, and traumatic
noci impulses reaching the brain; 2, auditory, visual, olfactory associations excluded;
3, nerve blocked by cocain; patient in anoci-association. (After Crile.)
this subject; we consequently prefer to use throughout either o.25
or o.5 per cent. novocain with adrenalin, even though its effect may
not last much beyond the time consumed in the operation. The em-
ployment of the anoci principle is graphically illustrated in Fig. 22,
taken from Crile. Figures 23 and 24, taken from the same author, show
in a striking way the effects of shock and fear upon the brain-cells of
animals. Figures 25 and 26 show the comparative results obtained by
different methods of anesthesia, and illustrate very forcibly the advan-
tages of the anoci principle. This latter work of Crile is bound to
add a great impetus to local anesthesia, whether we employ it in

ANOCI-ASSOCIATION I97
Anoci shocked dog.
Cerv. cord severed.
- -
- -
---
N2O anesthesia.
(From Crile.)
Ether anesthesia.
Normal rabbit. Rabbit. Fright.
- º º
º ºs s ***.
º º º
º º & º º
-- "a º º º º
* ºr ºº. º
º º º
* º - 4.
| | * º, º
Warºa/ º º
º
} º
- º -
Rabbit two hours after fright.
Characteristic changes
in brain cells in fright.
Hyperchromatic during
fright. Exhausted after
fright.
Fig. 24.
Characteristic changes
in brain cells in shock.
Note swelling and rup-
ture of nucleus and nist-
bodies.
(From Crile.)






I98 LOCAL ANESTHESIA
association with light cortical general anesthesia or the preliminary
hypodermic of morphin and Scopolamin, or both.
The survival or failure of any method advocated for practical
daily use must rest entirely upon the clinical results obtained. The
9 8 9 9 | 00 | 0 || || 0 2 |03
e at S. 70
Ether.
N2, 0.
mo ci
Fig. 25.-Abdominal hysterectomy. The temperature: Each heavy line represents
the average 5.oo P. M. temperature of Io patients during the first four days after
operation. The pulse: Each heavy line represents the average 5.oo P. M. pulse rate
of Io patients during the first four days after operation. (From Crile.)
38 9 3 | 00 | 0 || | |02 |03
Ether.
0.
Ånoci
Fig. 26.-Thyroidectomy. The temperature: Each heavy line represents the aver-
age 5.oo P. M. temperature of Io patients during the first four days after operation.
The pulse: Each heavy line represents the average 5.oo P. M. pulse rate of Io patients
during the first four days after operation. (After Crile.)
prime object of all surgery, as well as all medicine, is the relief of suffer-
ing and the prolongation of life; those measures which attain these ends
with the least disturbance to the patient and the least suffering must
ultimately prevail to the exclusion of all other harsher and less agree-
able methods. - -


ANOCI-ASSOCIATION I99
Here local anesthesia in its anoci features, as applied to major
operations, has a decided claim in offering to the patient a pleasanter
convalescence.
How often one hears the complaint from a patient disturbed by
a persistent postanesthetic nausea, or racked by gas pains following
a laparotomy: “Oh, doctor, if I had known what I had to go through
I would never have consented.” Compare this picture with a similar
case operated by local anesthesia and note the contrast; the great
nightmare of ether, with its resulting nausea removed, and the entire
absence or reduction to a minimum of postoperative gas pains in
abdominal operations, or lessened painful reaction in other wounds,
producing a pleasanter, easier, less dreaded convalescence, with
practically no disturbance of the nervous equilibrium, with no ex-
hausting demands for unnecessary and wasted energy upon the
Central nervous system, less constant and exacting attention on the
part of nurses and doctors afterward, less use of the stomach-tube,
and less of hot stupes and high rectal flushes. These are the ad-
vantages offered by local anesthesia. Crile states that 90 per cent.
of his cases operated by the anoci principle have no unpleasant recol-
lection of the day of their operation. How can we explain the differ-
ences?
First, The absence of a general anesthetic, or its superficial use
for purely cortical anesthesia, removes the postanesthetic nausea,
which in itself is a decidedly disturbing factor in its constant retch-
ing and efforts at vomiting in disturbing the field of operation, par-
ticularly So if it is abdominal, lighting up with each effort new pains by
the tug and pull on the incised and sutured parts, requiring for relief
repeated hypodermics of morphin, which often aggravate the nausea.
Second, The blocking process by the local anesthesia in the field
of operation absolutely prevents all reflexes from reaching the sur-
rounding parts as well as centrally, consequently there is less dis-
turbance of their normal equilibrium and less after-reaction, and
this action can be prolonged for several days when quinin and urea
are used for this purpose, as recommended by Crile.
The final proof must then come in the clinical use of these measures,
and this proof I feel has been already amply furnished by the pioneer
workers in this field and to be now passed the experimental stage and
beyond all controversy. I have often seen cases operated for serious
abdominal conditions practically free from postoperative disturb-
ance and hard to convince that they had gone through a severe major
Operation.
CHAPTER XII
INTRA-ARTERIAL ANESTHESIA
THE first records we have of the injection of cocain into arteries
was with a view of determining its relative toxicity when administered
in this manner.
Alms in 1886 was the first to report its anesthetizing effect in the
field supplied by the artery; he experimented by injecting cocain
into the iliac artery of the frog, in this way carrying it to the entire
distribution of this vessel in the lower limb, bringing about Com-
plete motor and sensory paralysis.
Since the introduction of Bier's intravenous anesthesia, investiga-
tors began to consider the arterial route as a means of diffusing anes-
thetic solutions for surgical purposes. The method was first used
by Oppel and Goyanes, who injected weak Solutions of cocain into
arteries between two constrictors; their results were quite interesting,
but not of much value clinically.
The method has, however, recently been brought forward by
several operators working along slightly different lines.
Terminal arterial anesthesia has been introduced by Ransohoff,
of Cincinnati, who reported his results in the “Lancet-Clinic,” 1909,
and later, in a more thorough article, in the “Annals of Surgery,”
1910. The following is from Prof. Ransohoff’s report:
“CASE I.—Male, aged seventy-two, in the service of Dr. Robert Carothers, through
whose courtesy I am enabled to report this case. The patient had been suffering for
three years from a chronic osteomyelitis of the hand, which became so painful as to neces-
sitate an amputation. His age and condition contra-indicated general anesthesia. Opera-
tion at Good Samaritan Hospital, July 12, 1909. An Esmarch bandage was applied about
the arm 2 inches below the insertion of the deltoid. Under infiltration anesthesia the
brachial artery was exposed and the needle of a hypodermic syringe inserted into its
lumen, and I c.c. of a 2 per cent. cocain solution injected into the artery in the direction
of the blood-current. In two minutes anesthesia was absolute and antibrachial amputa-
tion done without the patient’s knowledge.
“There are two features of special interest in this case—the rapidity of anesthesia and
the fact that the operation was performed without the patient’s knowledge. After the
operation had been completed the patient asked when we would begin. This absolute
anesthesia is a salient feature of this method, as well as one of its greatest advantages.
200
INTRA-ARTERIAL ANESTHESIA 2OI
“CASE II.-Female, aged fifty, service of Dr. Robert Carothers, Cincinnati Hospital.
Diagnosis: Osteoma of scaphoid bone. Operation: Esmarch strap applied tightly above
knee. Under infiltration anesthesia the anterior tibial artery was exposed just above the
ankle and I c.c. of 1 per cent. cocain solution injected into the artery. This was immedi-
ately followed by complete anesthesia of the entire foot, during which the osteoma was
removed without the patient suffering the slightest pain. The further history was unevent-
ful.
“A Series of animal experiments was now done to determine the
certainty of anesthesia, its safety, and its applicability in opera-
tions other than amputations. In all ten experiments were done—
the first series in rabbits, the second in dogs. It will be seen that
in operations other than amputations a 2 per cent. Cocain Solution
is too strong to be consistent with safety, because of the danger of
absorption into the general circulation. A o.5 per cent. Cocain Solu-
tion was used and found in every way adequate.
“In the experiments on rabbits the femoral artery was selected
as the site of injection. The artery was exposed in the upper part of
Scarpa's triangle; I c.c. of o.5 per cent. Cocain Solution was injected
into the artery in the course of the blood-stream, and tests for anes-
thesia were immediately made. The experiment was in each case
controlled by testing the sensibility of the other leg and distant parts
of the body. The following uniform results were obtained: Irritation
of the anesthetized leg caused no response; that is, the animal gave no
evidence of pain, as, for instance, by drawing away the leg. Irrita-
tion of the opposite leg was invariably followed by all the evidences
of pain. -
“Experiment I. The bone was exposed as roughly as possible,
the knife rubbed up and down on the bone, stripping the periosteum.
No pain.
“Experiment 2. The femur was broken by manual force and the
two ends of the bone rubbed roughly together.
“Experiment 3. The foot was charred with a Bunsen flame. No
evidence of pain.
“Experiment 4. The femoral artery was torn, causing great
hemorrhage, and necessitating the abandonment of the experiment.
This accident, very likely to occur in the thin-walled artery of a rab-
bit, is impossible, as will be shown, in the thicker walled artery of a .
dog or man. -
“Experiments 5 and 6 were in all respects similar to the preced-
ing experiments, and need not be detailed.
“The disadvantage of working on rabbits is manifest. The punc-
ture of the thin-walled artery was invariably followed by hemor-
2O2 LOCAL ANESTHESIA
rhage, necessitating the killing of the animal after the experiment.
The perfection of the anesthesia was determined, it is true, by the
rabbit experiments, but not its freedom from danger. Therefore
another series of experiments was done on dogs and the animals
allowed to live.
“Experiment 7. Large black-and-tan dog. Under ether anes-
thesia the femoral artery was exposed and 2 c.c. of O.5 per cent. cocain
solution injected into the artery. The animal was then lifted from the
dog board and allowed to recover from the anesthesia. After fifteen
minutes the dog seemed perfectly normal, running about the room in
the usual way. It was particularly noticed that there was an ab-
sence of any muscular paralysis. The animal was now tested for
anesthesia. The anesthetized leg was pinched, scratched, and slightly
burned. No symptoms of pain were elicited. Irritation of the other
leg and other parts of the body gave immediate response. After test-
ing the anesthesia for half an hour the wound was united with a
continuous suture. During the maneuver the most perfect demon-
stration of the anesthesia was obtained. The point of injection into
the artery lay about the middle of the wound. The lower half of the
wound was sutured without any evidence of pain, the animal lying
perfectly quiet and seemingly unconcerned. As soon as the needle
entered the skin above the point of injection the animal gave all
evidences of severe pain—squealing and struggling. This demon-
strated that the anesthesia extends to the point of injection. The dog
was watched for a week, during which no untoward symptoms were
evidenced. The animal then escaped, none the worse for his expe-
rience.
“Experiment 8 was in every particular similar to the above ex-
periment. The subject was a smaller animal, and only I c.c. of o.5
per cent. cocain solution was used.
“Experiment 9 is, according to present indications, more of scien-
tific interest than of practical value. The dog was large. Under
ether anesthesia the common carotid artery was exposed and 2 c.c.
of o.5 per cent. cocain solution injected into the artery. The wound
was closed with a continuous suture and the animal allowed to re-
cover from the anesthesia. After about fifteen minutes recovery
was complete and the animal was apparently normal. What was
most interesting was the complete absence of any deviation from
normal intelligence. The animal ate and drank from a bowl, also
gave evidence of knowing what was going on about him. The animal
was now tested for anesthesia. The results were most gratifying.
INTRA-ARTERIAL ANESTHESIA 2O3
There was a complete anesthesia of the entire head, face, and upper
part of the neck. The skull was exposed and a piece of bone chipped
out. Deep incisions were made into the skin of the face, ears, and
neck. Even the very sensitive nose and lips were scarified without
causing pain. Irritation of other parts of the body elicited symptoms
of pain. The bilateral anesthesia of the face and head may be ex-
plained by the very free anastomosis between the two carotid sys-
tems. A very interesting feature of this experiment is that sight
was not interfered with, as shown by persistence of lid reflexes.
“Experiment Io. Medium-sized dog. Under ether anesthesia
the femoral artery was exposed and I c.c. of o.5 per cent. novocain
Solution was injected. The experiment was a failure, the dog show-
ing no diminution of sensation.
“The nature of the anesthesia is terminal—that is, the cocain is
carried by the capillaries to the individual nerve-endings. The solu-
tion is diffused through the capillary walls into the surrounding tis-
Sues, and very little, if any, is returned through the veins to the
general circulation. This is shown by the purely local character of
the anesthesia. -
“The following technic is to be used in man: The main artery
Supplying the part to be anesthetized is exposed under infiltration
anesthesia. An Esmarch strap is now bound around the limb some
distance above the point of proposed injection into the artery. The
Esmarch should be used as in the Bier hyperemic treatment; that is,
Snug enough to constrict the veins, but not so tight as to interfere
with the arterial circulation. From 4 to 8 c.c. of o.5 per cent. cocain
in normal salt solution should be injected into the artery in the direc-
tion of the blood-stream. The needle used should be as fine as pos-
sible. After anesthesia is complete the Esmarch may be tightened
if perfect hemostasis is desired. At the end of the operation the
Esmarch is removed and the wound closed. The maximum dose sug-
gested, that is, 8 c.c. of o.5 per cent. cocain solution, contains only
o.6 cocain, a safe dose. This method of anesthesia is an ideal one for
certain areas of the body when general anesthesia is contra-indicated.
It is particularly applicable to the upper extremity, where the brachial,
radial, or ulnar artery may be exposed with little difficulty.”
In commenting upon the procedure, particularly Experiment 9,
in which 2 c.c. of o.5 per cent. cocain was injected into the common
carotid artery (he does not say which side) and produced a “com-
plete anesthesia of the entire head, face, and upper part of the neck,”
while not questioning the correctness of the observations, it is inter-
2O4 LOCAL ANESTHESIA
esting to know just how the cocain acted. Was it distributed to the
parts by the external carotid on the side injected? If so, it is difficult
to understand how it reached the other side in sufficient quantities
to produce anesthesia, unless the external carotid of that side had
been previously ligated; in this case the blood could easily cross over
through the numerous anastomoses. Or, did it reach the centers of
the fifth nerve (the nerve principally concerned in the sensation of
these parts) in the floor of the fourth ventricle through the distribu-
tion of the internal carotid artery? If this were the case, it is more
readily understood how both sides were equally affected; but, on
the other hand, the rest of the brain was bathed in a solution of the
drug equally as strong, and should have shown more disturbance of
sensation of the entire body as well as paralyzing other centers. Just
where the general centers for the pain are we do not know; but we
know that it is the brain that feels, and that it is capable of general
anesthesia by cocain injected into the blood-current, as shown by Dr.
Harrison's experiments upon himself, mentioned elsewhere in this
volume, and Ritter's experiments upon dogs. (See General Anes-
thesia with Cocain.)
The fatal dose of cocain injected into the arteries is eight to ten
times greater than the intravenous dose (Oppel), but here he was
speaking of arteries in the extremities, where the effect of the cocain
was largely reduced and weakened by making the circuit of the
blood-stream, and much of it being fixed by contact with the com-
paratively large capillary area. As its toxic action is due entirely to
the amount of the drug reaching the central nervous system through
the circulation, when delivered into such arteries as the carotid, the
ratio between the intravenous and intra-arterial toxicity must here
be reversed and the intra-arterial dose here be many times smaller.
Besides, when delivered intravenously most of that reaching the
heart is distributed to the trunk and peripheral parts, with the bulk
of the circulation and only a small part of it, certainly not over one-
fourth, reaching the brain by the vessels going in that direction.
With these facts it is hard to reconcile the two observations, that by
Dr. Harrison, who injected 5 grains intravenously in himself in thirty
minutes and obtained general anesthesia of the entire body, and that
of Dr. Ransohoff, who injected into the carotid 2 c.c. of a o.5 per cent.
solution, o. I 5 grain; although the dog was large, it must have been a
relatively good-sized dose for that method of administration, and pro-
duced only an anesthesia of the head, face, and upper part of the neck.
Letting alone the action of the drug in this particular case of carotid
INTRA-ARTERIAL ANESTHESIA 2O5
injection, the method of arterial anesthesia is certainly ingenious and
of scientific interest. It is too early yet to state of what practical
value it may become, as the writer has had but a limited experience
with the method, and it has had but a limited trial in the hands of
others who have introduced it. The fact that the main artery of
the part must first be exposed is not in itself an objection, for the
same dissections frequently are made to expose nerves for regional
anesthesia. Of course the method should be tried only in those hav-
ing healthy arteries; in such vessels the puncture of a fine hypodermic
needle is not likely to be followed by any after-result. It would, how-
ever, seem preferable, in operating upon the extremities, where infil-
tration and nerve-blocking cannot be used, to use venous anesthesia,
which is a simpler method, and when properly carried out produces
very satisfactory results and is free from any possible after-effects.
The following case, operated upon by the author, presents Some
features of interest:
M., an aged man, presented an advanced carcinoma of the parotid gland, with his
general condition contra-indicating the use of general anesthesia. It was decided to ligate
the external carotid at its origin, as a preliminary step, after first utilizing it for arterial
anesthesia. The problem then presented itself as to how soon after the injection should
the ligature be applied; if done too soon no good would be accomplished, as the injected
solution, not having reached the capillaries, could not readily diffuse into the tissues,
and if delayed too long it would be swept into the return circulation.
Adrenalin was accordingly utilized for determining the proper time for the applica-
tion of the ligature. After free exposure of the carotid, with the ligature in place but not
tied, 5 c.c. of a 1 per cent. novocain solution, containing 15 drops of adrenalin (I: Iooo),
was now slowly injected with a fine needle; in ten seconds, and before the entire quantity
had been injected, the effect came like a flash in the peripheral parts; the face, cheek, and
parotid region, previously florid with dilated capillaries, was suddenly blanched almost
a perfect white; the effect was so sudden and complete that it was startling and extended
over the entire side of the face and head; the remaining solution was now quickly injected
and the ligature tied.
Tests for sensibility showed a decided diminution over the entire blanched area, but
not sufficient to permit operation. This was probably due to the small amount of novo-
cain used, and its too slow injection to permit of the maximum amount reaching the
peripheral parts at one time in such a vascular region. We now injected the trigeminus
at the base of the skull and obtained perfect anesthesia, proceeding with the operation in a
completely ischemic field.
This procedure of the utilization of adrenalin suggests itself as a
simple and reliable means of determining when the injected anesthetic
has reached the capillaries and may prove a useful adjunct. It also
occurred to the author that it might find an occasional field of use-
fulness in ligating a large vessel in the presence of anomalous arterial
formation when other tests, as peripheral pulse, etc., give uncertain
results.
2O6
LOCAL ANESTHESIA
INTRAVENOUS ANESTHESIA
This unique and simple method of anesthesia was introduced by
Prof. August Bier, of Berlin, to whom medical science already owes
Fig. 27.-a-b, The prox-
imal; c-d, the distal or pe-
ripheral bandage; wb, vena
basilica; we, vena cephalica;
vm, vena media; +, the
place where the injection
may be made in the ceph-
alic and at a corresponding
point in the basilic veins.
Shading shows area of sen-
sibility below the proximal
bandage (Bier).
much. In addition to this, his latest dis-
covery in this field, he has done much to-
ward spinal analgesia in placing it upon the
plane which it now occupies. This method
was first presented by Bier before the Thirty-
seventh Congress of German Surgeons, April,
1908. It is applicable only to the extremi-
ties. The limb to be operated upon is first
rendered completely ischemic by an Esmarch
or soft-rubber bandage applied from the distal
end to a point above the proposed site of in-
jection. This must be done thoroughly, the
presence of blood in the veins interfering with
the production of a perfect anesthesia. A
soft-rubber bandage (the kind used for stasis
hyperemia) is now applied at the upper part
of the ischemic area; it must be tight enough
to prevent the circulation entering the part,
and should be applied over a broad area, so
that the pressure does not become painful.
A second similar bandage is placed below the
proposed site of injection, from 4 to 6 inches
below the first. Under infiltration anesthesia
the vein is now exposed. The principal vein
of the part should be selected and not one of
its radicles. In the case of the leg, the saphe-
nous; in the case of the arm, the median
cephalic or median basilic, or one of their
large trunks, in case the injection is made
below the elbow. The vein should be ex-
posed as near the upper bandage as possi-
ble, ligatures passed around it, and the upper
end tied. An infusion cannula is now passed
into its lumen, either through an opening
or by having the vein sectioned across.
This is firmly secured in the lumen of
the vein and the anesthetic solution in-
jected through the cannula. If the operation

INTRA-ARTERIAL ANESTHESIA 2O7
is upon the upper extremity, 50 c.c. of o-5 per cent. novocain in normal
salt solution is used; if upon the lower extremity, 80 c.c. of the same
solution is used. Any large syringe can be used for making the in-
jection, although to facilitate the work a special syringe has been
devised (Fig. 28). A stout piece of tubing can be used for making the
connection between the nozzle of the syringe and the cannula within
the vein; it must be firmly attached to both and the syringe be in
good working order, as it requires some little pressure to drive the
solution into the veins. The Matas infiltration apparatus is admirably
suited for this injection. The injection should not be too rapidly made,
but done slowly, allowing time for the solution to flow into the veins,
which are seen slowly distending as they are filled with the solution.
The solution diffuses through the vein walls into the surrounding
tissues, the distended veins becoming less and less distinct until they
Fig. 28–Large syringe for Bier intravenous anesthesia. (From Braun.)
are no longer discernible. The valves in the veins offer no obstruc-
tion to the injection, as they are forced by the fluid and the distention
of the veins.
Anesthesia is said to be produced in from ten to fifteen minutes
in the area between the bandages (direct anesthesia). In the parts
distal to the lower bandage anesthesia is complete in from fifteen
to twenty minutes (indirect anesthesia). Anesthesia does not reach
quite to the upper bandage, and frequently leaves a strip on the side
opposite to the vein which reaches down to the second bandage
only partially, or not at all, anesthetic.
The circumferential spread of the anesthetic solution can be
favored and increased by massage and kneading of the parts after the
injection has been made and while waiting for the anesthesia to
develop.

208 LOCAL ANESTHESIA
The muscular relaxation is said to be more prompt and pro-
nounced than under ether anesthesia.
The duration of the anesthesia is absolutely under control and
persists as long as the upper bandage remains in place, and rapidly
disappears after the removal of the latter, sensation returning in a
very few minutes. For this reason it is necessary that the entire
operation be completed and, if possible, the dressings applied before
the upper bandage is removed. The duration of the operation is said
to bear no relation to the rapidity of the return of sensation.
Care should be exercised in securing all bleeding-points, which
are easily overlooked when operating by this method. Salt solution
injected through the cannula, when operating in the area of direct
anesthesia, may be used to show the points of venous hemorrhage.
After the completion of the operation the veins may be washed out
with salt solution to remove any excess of the anesthetic solution
which may still remain in them. This process does not lessen the anes-
thesia or seem to hasten the return of sensation, which confirms the
observation that the anesthetic agents have formed compounds with
the tissue-cells which is only broken up by nutrition with arterial blood.
In the numerous cases reported operated on by this method no
cases of intoxication from the anesthetic used have been recorded.
In the case of amputation, or extensive operation in the area of
direct anesthesia, the washing out process of the veins may be omitted,
as the incisions furnish ample opportunities for the escape of any ex-
cess of solution. -
In preparing the limb for injection it is said to cause less dis-
comfort to sensitive patients if the main artery of the part is first
compressed and the limb elevated and rendered ischemic in this
position. Should the pressure from the upper bandage become
troublesome to the patient during operation, an additional bandage
can then be applied within the anesthetic area and the upper one
removed.
Precautions suggested to guard against toxemia in addition to
the washing-out process above mentioned are to release the bandages
gradually after the completion of the operation or to tighten the upper
one after it has been released for a few moments.
Here, as in all major operations under any method of local or
regional anesthesia, it is desirable to give a preliminary hypodermic
of morphin, ; grain, with scopolamin, Tºo grain, about one hour
before the operation. It greatly lessens the fears and anxiety of the
patient and overcomes any undue sensitiveness.
INTRA-ARTERIAL ANESTHESIA 209
The operative possibilities under this method are not limited to
any particular class of operations, but include the entire range of
surgical interventions upon these parts.
The only contra-indications mentioned for this method are diabetes,
advanced arteriosclerosis, and senile gangrene.
In a recent article Prof. Bier has suggested exposing the vein
under local anesthesia before rendering the parts ischemic and identi-
fying it by passing a ligature around it, as it is not always easy to
recognize the one wanted in ischemic tissues, particularly if Sur-
rounded by much fat; the field can then be covered by a sterile towel
and the process proceeded with.
14
CHAPTER XIII
GENERAL ANESTHESIA THROUGH THE INTRAVENOUS
INJECTION OF LOCAL ANESTHETICS
RITTER, experimenting in Payr's clinic, produced complete general
analgesia by injecting into Superficial veins of dogs Io C.C. of a I per
cent. Solution of cocain, or 5 c.c. of a 3 or 5 per cent. Solution in a O.I
per cent. Salt solution. The animals lay perfectly quiet, but alert.
Respiration and circulation were not disturbed, but they were com-
pletely insensible to every kind of irritation that could be used, even
to the actual cautery applied to the penis, vagina, anus, tail, face,
ear, and lining of the mouth. There was no sign of pain, and the
dogs wagged their tails during these performances. Only when for-
ceps were applied to the tongue did they seem to object, but here not
apparently from pain.
The duration of the anesthesia was from fifteen to twenty min-
utes or longer, and was not followed by serious after-disturbances.
Only a few showed any unpleasant by-effects, and these were small
animals upon which the larger doses had been used. One dog, how-
ever, always reacted in the same way, even to small doses. The dis-
turbances were always of the same kind, the animal becoming very
restless, tossing his head about, and, if placed on the floor, ran around
in circles. This would continue for about fifteen minutes, after
which time the animal quieted down and remained apparently nor-
mal. Actual convulsions were never observed with any dosage. None
of the larger dogs showed any by-effects.
Still more interesting are the observations made by Dr. B. W.
Harrison upon himself, and reported in the Boston Med. and Surg.
Jour., February 2, 1911. The doctor showed great courage in using
upon himself, by the method he employed, what would have been
considered a thoroughly toxic dose of the drug; but he observed the
precaution of proceeding very slowly and stopping with the first
unpleasant symptoms. He states that, except for minor operations,
there had been no other use of cocain or allied drugs upon himself.
The experiment was performed as follows:
210
THE INTRAVENOUS INJECTION OF LOCAL ANESTHETICS 2 II
Into one of the superficial veins on the back of the hand there
was slowly injected 5 gr. of cocain in a 2 per cent. Solution. The
injection was made very slowly, and was completed in thirty min-
utes. It was deemed advisable to stop here, as dizziness and palpita-
tion occurred. Tests of the patient's condition as to general anesthe-
sia were now made, and were found to conform in an incomplete way
with those observed in animals similarly experimented with. There
was fairly marked analgesia everywhere. An incision # inch long, and
carried well down into the fat, was made on the anterior surface of the
leg. The incision could be felt, but caused a mere trifle of pain.
When several small nerves in the fat were cut each caused a small
twinge of pain, but, apparently, operative procedure might readily
have been undertaken with only moderate discomfort. Two hours
later a similar incision was made on the opposite leg; by now the sen-
sation of pain had nearly recovered its normal intensity. During the
experiment cerebration was normal, except for a restless inability to
keep the mind long on one subject. Motor power was unimpaired.
This experiment and those on dogs by Ritter are highly inter-
esting, and, at least, of scientific value. The enormous dose neces-
sary upon Dr. Harrison, and then producing only an imperfect anal-
gesia, makes it an impossibility in human surgery. The dose used
by Dr. Harrison was several times that necessary to show toxic symp-
toms, and may have proved fatal had he injected it all at once, but
he made the injection slowly over a period of thirty minutes.
It is interesting to compare the results obtained by these injec-
tions with that by Prof. Ransohoff, when he injected o.15 gr. of
cocain in the common carotid of a dog, and obtained only analgesia
of the head, face, and upper part of the neck. (See Arterial Anesthe-
sia, Experiment 9, and the discussion which follows.)
A comparison of the toxicity of cocain, when injected in the
various ways, is given by Oppel as follows:
“Subcutaneous injections are two to three times less dangerous
than the arterial and fifteen to twenty times less dangerous than the
intravenous injection, and arterial injections are eight to ten times
less dangerous than the intravenous.” (Here he was no doubt ex-
perimenting with arteries of the extremities, but he does not state.)
CHAPTER XIV
THE UPPER AND LOWER EXTREMITIES
“As a general proposition, it may be safely asserted that all opera-
tions can be made painless by local or regional anesthesia in all parts
of the body in which the circulation can be absolutely controlled by
circular constriction. Hence, the entire surgery of the upper and
lower limbs (with exceptions to be considered later) can be made
tributary to these methods. It is in the surgery of the extremities
that the combined local (infiltrations) and regional (neural) anesthesia
has attained its degree of efficiency and accomplished its most con-
vincing, if not most brilliant, results. On the other hand, the effi-
ciency and applicability of these methods is decidedly restricted, im-
paired, and at times wholly inefficient at the root of the limbs. This
is more especially the case in the hip and gluteal regions, where, on
account of the overlapping of the cutaneous nerve distribution and
because of the great depth of the most important nerves—as, e. g.,
the sciatic, where it issues from the pelvis—it is impossible to expose
the great nerve-trunks without inflicting an additional traumatism,
which is scarcely compatible with the conservative aims of the local
anesthetic methods.
“It is only fair to state that these objections do not apply to all
cases, and that even in these most difficult regions many perfect
successes can be obtained by purely local and intraneural methods
when they are applied to suitable subjects. This is particularly true
of emaciated, wasted patients, in whom disarticulation at the hip
can be performed by simple edematization and intraneural infiltration
as effectively as in the minor amputations and disarticulations of the
fingers and toes” (Matas).
In the upper extremities the difficulties to be encountered are
much more successfully met by the comparatively easy access to the
brachial plexus, which can be exposed and infiltrated above the
clavicle.
But whatever doubts may exist as to the invariable success of
cocain and its allies in controlling the sensibility of the root of the
limbs, there can be none in asserting that all operations, including
212
THE UPPER AND LOWER EXTREMITIES 2I3
amputations, disarticulations, and excisions below the insertion of
the deltoid in the arm, and below the middle third of the thigh in the
lower limbs, can be made painless by purely local or neural (peripheral)
methods of anesthesia. In anesthetizing the extremities the methods
will vary with the individual regions, and the technic will demand
more skill and anatomic knowledge as the surgeon proceeds from
periphery to center. In all major procedures, in which a large part
of the thickness and circumference of the limb is to be exposed to the
knife and to painful manipulations, the neuroregional methods is to
be preferred, as in excision of bones and joints and in amputations.
In more Superficial or well-circumscribed lesions the simple infiltra-
tion method of Schleich will be most applicable. In thin and marasmic
subjects this method will also find frequent and ready application
because of its greater simplicity, even when amputations are required,
provided they are strictly typical and do not involve extensive ex-
Cursions away from the infiltrated area. But whether the method
adopted be the edematization of Schleich or the neuroregional method,
the circular elastic constrictor applied on the Corning principle should
be applied after the analgesic drug has been injected and the ex-
Sanguination of the limb by elevation and gravity has been obtained.
The introduction of vein anesthesia by Bier has greatly simplified
all procedures upon the extremities where this method can be em-
ployed; however, there still remain many conditions in which it cannot
be successfully used—the necessary appliances may not be at hand, or
the operator may prefer to use other methods. -
The ability to control the blood-supply in the extremities greatly
facilitates all surgical procedures in these parts, and in the use of
local anesthetics intensifies and prolongs their action.
The course of the long cutaneous trunks is fairly constant in both
upper and lower extremities, and should be carefully studied, as well
as their points of emergence through the deep fascia; the smaller cuta-
neous branches are, however, subject to variations within certain
limits, and cannot always be definitely located. But the main trunks
of these parts are quite constant throughout their entire course and
can be easily reached, either through deep paraneural injections
along their course or by free exposure and direct (intraneural) injec-
tions.
In all operations upon the bones it must be remembered that bone
and cartilage have no sensation, but that the periosteum, perichon-
drium, and synovial membranes are nearly as Sensitive as the skin;
bone-marrow is also slightly sensitive.
2I4 LOCAL ANESTHESIA
In operating here by infiltration the periosteum should be in-
cluded; after this has been infiltrated or denuded from the bone no
further sensation is felt.
In operating upon bones for inflammatory conditions, such as
periostitis or osteomyelitis, it is preferable always to use the regional
methods of anesthesia, but in cases where this is not feasible, or in
the absence of inflammations, where it is preferred to operate by in-
filtration, as in the removal of an osteophyte or for a simple osteotomy,
in such cases it is desirable, where the bone is superficial and easily
accessible, to infiltrate the periosteum before making the incision;
the infiltration is done with a long needle passed down from the skin
from two or more points and directed in different directions, so as to
embrace the entire operative field on the bone (see Fig. 15). In case
the bone is deeply situated or overlaid by heavy muscles, as in the case
of the femur, it would be preferable to anesthetize the periosteum later
after the bone has been exposed by the division of the overlying soft
parts. Where the periosteum has been well anesthetized the use of
chisels or other bone-cutting instruments is unaccompanied by any
pain. In operating by regional methods the injections should be
made at sufficiently high levels to include the nerve supply to the
periosteum when possible, otherwise the periosteum will have to be
infiltrated. The humerus receives its nerve-supply from the musculo-
spiral and musculocutaneous nerves; the radius and ulnar, from the
median nerve; the elbow-joint and wrist receive nerves from the three
large trunks in the arm; the femur, from the sciatic and obturator
nerves; the tibia, from the anterior and posterior tibial nerves; the
fibula, from the peroneal; the knee-joint, from the internal and external
popliteal, obturator, and crural nerves.
The entire contents of the joints contained within the synovial
sacs can be anesthetized by passing a needle into the sac and filling
it to a point of moderate distention with solution No. 2 (o.5 per
cent. novocain), or slightly lesser quantity of a stronger solution, and
allowing it to remain for about five minutes, when it can be with-
drawn or will escape from the incision.
Fractures.—Local anesthesia has been used occasionally in reduc-
ing fractures of the long bones. While in certain cases it may be useful
where general anesthesia is contra-indicated, it is certainly not the
method of choice, for with it we do not get the complete muscular
relaxation so necessary for the perfect reduction of the fractured frag-
ments. Lerda, in the “Centralblatt für Chirurgie,” 1907, states that
during the last two years extensive use has been made of local anes-
THE UPPER AND LOWER EXTREMITIES - 2I5
thesia for fractures in Isnardi's service at Turin, where he is assistant;
he applied this technic in 30 cases before reduction of the fracture and
has never observed the slightest inconvenience. He uses a long, strong
needle, and injects the anesthetic mixture at various points between
the fractured ends and tangential to them, so that the entire focus of
the fracture, the bone-marrow, periosteum, and surrounding tissue
become impregnated with the anesthetic. He adds a drop of I: Iooo
Solution of adrenalin to each cubic centimeter 'of a o.5 per cent.
Solution of cocain. Sometimes as much as o.o8 gram of cocain (about
I grain) was injected without appreciable by-effects. The contraction
of the vessels aids in preventing hematoma at the point. The anes-
thesia is generally complete in about eight minutes. Not only is the
pain abolished, but the fracture can be reduced much more perfectly,
attaining results otherwise impossible without general anesthesia.
While the method recommended by Lerda has the advantage of
simplicity, it may be preferred in many cases to use regional anes-
thesia, which produces a certain amount of muscular relaxation, though
always less than that obtained from general anesthesia; for this reason
general anesthesia is always to be preferred except in those cases which
positively contra-indicate its use; here, where some form of anes-
thesia is needed in complicated cases, the local or regional methods
may prove of valuable assistance.
THE BRACHIAL PLEXUS
The nerves of the upper extremity are all derived from the brachial
plexus except the intercostohumeral; the lateral cutaneous branch of
the second intercostal, which crosses the axilla, pierces the deep fascia
at the inner side of the arm, and is distributed to the skin of the upper
parts of the arm on its inner and posterior surface; sometimes the third
intercostal gives off a similar branch. The brachial plexus is quite
easily exposed and blocked; for this purpose it should be exposed above
the clavicle by an incision running downward and outward from the
outer border of the sternomastoid over the course of the plexus (see
Fig. 69), which is easily recognized lying on the surface of the scalenus
medius, where each of its branches may be separately injected, each
with a few drops of o.5 per cent. novocain solution with a few drops of
adrenalin to the ounce.
The results of an intraneural injection of the brachial plexus are
shown in from five to ten minutes in a complete analgesia of the
shoulder and entire arm, and can be made use of in extensive opera-
tions upon these parts, and is particularly Suited to high amputations
216 - LOCAL ANESTHESIA
and disarticulations at the shoulder. Where the operative field enters
the region of distribution of the intercostohumeral nerve, this may be
blocked by a few drams of Solution injected subcutaneously along the
floor of the axilla on its outer and posterior border. All operations
above the elbow, when too extensive to be readily performed by infil-
tration, should be done by blocking the brachial plexus, thus con-
trolling all nerves, superficial and deep, of this part as well as the fore-
arm and hand. The localization and injection of the cutaneous
trunks of this region is unsatisfactory, as they are derived from a
variety of sources and overlap each other; Superficial or minor opera-
tions should, therefore, be done through infiltration, reserving block-
ing of the brachial plexus for the more extensive or major procedures.
Operations at or near the elbow, involving extensive dissections, resec-
tions, or amputations, had best be performed by the above method,
which, of course, may also be used for any operation on the distal
parts of the forearm or hand, but here it would be preferable to block
the nerves at the elbow.
“We believed in January, 1898, that in cocainizing the three
great nerves of the arm at the elbow by direct intraneural infiltra-
tion a considerable territory had been conquered from the domain of
general anesthesia. We were not then aware that a few months before
our first operation at the Charity Hospital the same principle had
been successfully applied to the lower extremity by the direct infiltra-
tion of the sciatic and anterior crural nerves in the performance of an
amputation of the leg. The credit of applying this direct intraneural
method in major amputations is due, I am pleased to say, to Dr. Geo.
W. Crile, of Cleveland, Ohio, whose remarkable and most exhaustive
experimental study of shock has made his name familiar to all readers
of surgical literature. It was precisely with the view of diminishing
shock that Dr. Crile was led to apply this method, which he very ap-
propriately designates the ‘blocking method,” because the infiltra-
tion of a nerve-trunk with cocain “blocks' or completely interrupts
the conduction of all afferent, irritant impressions made upon the
nerve below the blockade. Crile's first operation was performed May
18, 1897, and was suggested by the well-known experiments of the
physiologists, U. Mosso (1886) and François Franck (1894)” (Matas).
In a personal communication addressed to Dr. Matas, August 24,
1899, Dr. Crile stated that he had operated by the “blocking” method,
up to that time, on 7 patients, I of these being a case of amputation
at the shoulder-joint anesthetized by “blocking” the brachial plexus
above the clavicle. Dr. Crile's first case of amputation of the leg was
THE UPPER AND LOWER EXTREMITIES 2I?
reported to the Ohio State Medical Society in 1897, and excited the
attention of that body, but the great merit of his performance has
failed of Sufficient general recognition as one of the most brilliant and
useful contributions to the technic of regional anesthesia that have
emanated in recent years from an American surgeon.
“The effect of intraneural injections is usually and promptly felt,
and the effect is almost identical with that following the complete
Section of a mixed nerve. The only difference between this and com-
plete anatomic section lies in the remarkable fact that the voluntary
Control of the parts below the “blocked' nerves is largely retained,
So that the patient can materially assist the surgeon in his manipula-
tions. All pain conduction, all thermal sense is entirely lost; the
muscular Sense is impaired, but the deep reflexes are not lost; common
Sensation, tactile sense, is profoundly obtunded, but is not altogether
abolished. This affinity of cocain for the pain-conducting and thermal
fibers is one of the many remarkable features of its marvelous anes-
thetic action” (Matas).
In Some unusual cases the anesthesia following intraneural injection
has been retarded; this retardation has been sometimes so prolonged
that on more than one occasion I have felt worried at the prospect of
total failure. After waiting patiently for fifteen and in I case
twenty minutes, the characteristic subjective paresthesia began, and
in a few seconds thereafter the anesthesia was complete. Once
established, the anesthesia will remain as long as the circulation is
arrested by the constrictor, but in places where constriction is not
satisfactory, as at the groin (anesthesia of the anterior crural) and
at the brachial plexus, the nerves will remain anesthetized for forty-
five minutes to an hour, if a I per cent. novocain or a 4 per cent. beta-
eucain solution is used with adrenalin.
The anesthesia is more transitory if the weaker solutions are in-
jected, and for this reason a 1 per cent. novocain or 4 per cent, beta-
eucain should be preferred. Should the anesthesia begin to disappear
before the completion of the operation, the nerves can be re-injected.
In injecting the nerves great care should be observed to use the finest
needle, and to employ only fresh and perfectly sterile Solutions. The
fluids must be introduced into the center of the nerve with the needle
directed parallel to the nerve-fibers. Very few drops will usually
suffice to give the nerve a slight fusiform swelling at the point of in-
jection, which is characteristic of a thorough infiltration. Injections
made in this manner into a healthy nerve are never painful, provided
that the nerve is held slack, so that the injection can be made without
218 LOCAL ANESTHESIA
the least traction upon its fibers. Should traction be made upon the
nerve-trunk or tension made upon its fibers pain will be produced. In
case a nerve is inflamed from the extension of a surrounding inflamma-
tion intraneural injections will always cause pain. For this reason,
when practicing regional anesthesia the nerve-trunks should be in-
jected sufficiently high above the area of inflammation to be well
beyond a possible lymphangitis of the nerve-sheath. For instance,
if it is necessary to amputate a finger, and the inflammation extends
well up toward its base, it would be preferable to inject the nerves
above the wrist; or should it be necessary to open a deep palmar in-
jection or resect a metacarpal bone, and the inflammation extend to or
above the wrist, it would be better to inject the nerves at the elbow.
The paraneural injection of the brachial plexus both above the
clavicle and below it in the axilla, as has been recommended and prac-
ticed by some operators, but particularly in the axilla, is a far too
dangerous procedure to find a place in the operative methods of Con-
servative operators.
It is far better, safer, and surer, as well as quite simple, to resort
to the free exposure of the plexus above the clavicle, and inject each
individual nerve by the intraneural method, as first advocated by Crile.
These nerves are too large to be readily penetrated in effective quan-
tities by the anesthetic fluid with any degree of certainty, and the use
of strong solutions at these points, highly vascular and close to the
trunk, in any effective quantity is likely to prove dangerous, as ab-
sorption is active, and with no practicable means of retaining it in situ
by constriction.
Aside from the danger in the solution injected, if made in effective
quantity and strength, the anatomy of this region should be sufficient
to deter any but the most venturesome from this practice.
Above the clavicle the brachial plexus lies well to the base of the
neck on the scalenus medius, just to the outer border of the scalenus
anticus; the subclavian artery in this position passes behind the
scalenus with the plexus above, giving off in this neighborhood
branches of large size (Fig. 29). Many veins are encountered in
all directions, and, while their puncture with a fine needle would not
be of much consequence, an intravenous injection may prove a more
serious matter.
Below the clavicle the plexus lies to the outer side of the first por-
tion of the artery, embraces the second portion, and lies somewhat
more widely distributed around the third. The vein in both cases is
fairly out of the way.
THE UPPER AND LOWER EXTREMITIES 2I9
ºn-ºs meºe internal jugular
º vein
x * communicat
nºrmateurºtidº ºr ºf ººº-
art - trunk
nypo- -
*::::: external carotid art.
external maxillary * occipital art. * descend ºr of occipital art.
esser origital nerve
- - -
mylohyoid mer” º
submentañarſery.
rior ſº **
f tº trum -
on-ºx
superior thyreoid art. x -
sºmewoideus
descend ºr ºf hyperlºº ºnt origital nerve
- arressary nerve
sup, card, merrefrom symp. tº y
ascending cervical art phrenir zerº -
sternathyreoideº__ A superficial ºrval art. x
superior * - - |A - ascend ºr of transverse cerviral art.
reins - -
brachial plexus
-
- transverse rerviral art.
Scalenus anter, - -*.
- descend, ºr of transy terrical art.
inferior thyreoid …” transverse scapular art.
art. º clavicle x
* -
… axillary artery
º - thoraco-arromial artery x
º -- º acromial branch x.
- Deltoideus
axillary vein
ºf crphalie vein ×
gungi. -
thyreoid gland
thyrºv-cerviral tr. --
vertebral art. -
subravian art.
int, mammary art. -
inf laryngeal nerve
trachra-
Infer, thyreoid rein.
middle mrdiac
nerve
comm, carotid art.
lowest thyreoid
innominate.
Wein
Performlis
minorx
|
*::::::: br
of internal .
mammary art.
vertebral vein x.
internal jugular
vein k W
external jugular
rephalic vein -
ſº brachial plexits
- ~
Pectoralisminor, anterior thºraciº
nerves thūParodorsal nerve
tong thoracic thoraco-epiga- long thoracic nerve
vessels stric vein
Fig. 29.-The nerves and arteries of the deep layers of the neck and of the axilla.
(Sixth layer of neck, deeper layers of the axilla.) The greater portions of the infra-
hyoid muscles and of the common carotid artery have been removed; the clavicle has
been disarticulated at the sternoclavicular joint and sawn through at about its middle.
The pectoralis major and minor have been divided and the deltoid incised along the
deltoid branch of the thoraco—acromial artery. *, Accessory sympathetic ganglion.
(Sobotta and McMurrich.)
Notwithstanding these anatomic arrangements, paraneural injec-
tions have been made in both positions. The Kulenkampff method,
above the clavicle, has been favorably spoken of by Braun, and is done
















































22O LOCAL ANESTHESIA
in the following manner: That portion of the plexus is selected for
injection at the point where it passes over the first rib; in this position
the artery lies below and on the inner side, the clavicle above and in
front, the pleura and lung beneath (Fig. 30).
The direction of the brachial plexus, as it passes under the clavicle,
is at about right angles to the long axis of this bone, and passes under
at about its midpoint in the erect position of the body; for this
reason, as well as the fact that in this position the clavicle descends
slightly downward and forward, thus affording a better exposure of
the field, it is advised that the injection be made in the sitting position
(Fig. 31). The method of procedure is as follows:
Fig. 3o.—Thorax from above, after Kulenkampff. On one side is shown the posi-
tion of the brachial plexus and subclavian artery to the clavicle, on the other the
direction the needle should take in making the injection: a, Subclavian vein; b,
point of attachment of anterior scalenus muscle; c, subclavian artery; d, brachial
plexus; e, point of attachment of scalenus medius muscle. (From Braun.)
With the patient sitting erect the finger is passed over the mid-
point of the clavicle and accurately locates the artery by its pulsa-
tions; the skin and subcutaneous tissue is now lightly infiltrated, and
a long fine needle, unattached to the syringe, is passed in a direction
downward, inward, and backward from the midpoint of the clavicle
in such a direction that it aims at the spinous process of the second or
third dorsal vertebra; the distance to be penetrated and the amount of
fat vary, but it is usually from 2 to 4 cm., the plexus lying just under
the deep fascia. When the plexus is reached a slight radiating pain
or paresthesia is felt down the branches of the radial or median nerve

THE UPPER AND LOWER EXTREMITIES 22I
in the hand or fingers; at this point the needle is held stationary, the
syringe attached, and the injection made. The object in not attach-
ing the syringe earlier is that should the artery be entered blood will
flow; should this occur with a fine needle it is not likely to be of much
consequence, the needle being withdrawn slightly, and the point di-
rected a little more laterally. About 1o c.c. of a 2 per cent. novocain-
suprarenin solution is injected; the needle is now slightly withdrawn,
and an additional Io c.c. injected around in the neighborhood, to be
sure to reach any cord of the plexus that the first injection may have
missed.
It is said that when paresthesia occurs, which indicates that the
plexus has been reached, anesthesia is certain, and usually is es-
Fig. 31.-Position of patient for Kulenkampff brachial plexus injection. (From
Braun.)
tablished in from one to three minutes; occasionally, however, it
may require a longer delay, from ten to fifteen minutes; failure to
obtain anesthesia by this time usually indicates the need of another
puncture, when 5 to Io c.c. of a 4 per cent. Solution is used in the
same manner, except that the paresthesia in the extremity does not
occur unless the first injection has gone wide of the mark; should the
first injection fail, the second is not near so likely to succeed (Fig. 32).
In the hands of Kulenkampff and his associates, who injected a
large number of cases in this way, very few failures were recorded.
The duration of the anesthesia is from one-half hour to three
hours, and is associated with complete muscular relaxation of the
part.

222 LOCAL ANESTHESIA
Paraneural Injection Within the Aacilla.-The arm is abducted to
a right angle, the index-finger of one hand is passed up on the outer
17
Fig. 32.-Areas of distribution of cutaneous nerves (after Toldt), showing effect of
Kulenkampff plexus anesthesia: , Anesthesia; ++, hyperesthesia; [], normal
Sensation; I, Supraclavicular nerves; 2, circumflex; 3, external cutaneous; 4, musculo-
spiral; 5, radial; 6, musculocutaneous; 7, median; 8, radial (terminal branches); 9,
lateral cutaneous from second intercostal; Io, musculospiral; II, ulnar; 12, internal
cutaneous; 13, palmar branch of ulnar; I4, dorsal branch of ulnar; 15, palmar branch
of ulnar; I6, digital branches of ulnar; 17, digital branches of median. (From
Braun.)
side of the fossa, and the brachial artery located and slightly dis-
placed downward and inward; a long fine needle is now passed over
the tip of the finger and directed up in the long axis of the limb until

THE UPPER AND LOWER EXTREMITIES 223
well within the axilla, when the injection is made; the precaution
should be followed here, as elsewhere, when making an injection in the
neighborhood of vessels to continuously inject the
solution as the needle is being advanced; in this
way the vessels may be pushed aside and
their puncture avoided.
The needle is now passed behind the
artery near the insertion of the
tendon of the latissimus dorsi
to reach the posterior cord
of the plexus, and an
additional injec-
tion made at
Fig. 33–Cuta-
neous nerve areas of
the upper extremity (an-
terior view): A, Circumflex;
C, lesser internal cutaneous; D,
internal cutaneous; E, musculospiral;
F, musculocutaneous; G, ulnar; H,
median. (Campbell.)
Fig. 34.—Cuta-
neous nerve areas of
upper extremity (poste-
rior view): A, Supraclavicu-
lar; B, circumflex; C, musculo-
spiral; D, lesser internal cutane-
ous; E, internal cutaneous; F, ulnar,
G, musculospiral. (Campbell.)
this point; 3o to 40 c.c. of a 2 per cent.
novocain adrenalin solution is recommended
as the necessary amount (containing in this con-
centration a quantity of the drug clearly beyond the
safe limits). While the supraclavicular injection will
find a place in our recognized methods of procedure, this last injec-
tion within the axilla is, to say the least, unsurgical and is not to
be recommended.
The location and distribution of the nerve-supply from the
elbow down should be carefully studied for the application of regional
























224 LOCAL ANESTHESIA
methods of anesthesia to these parts, particularly the cutaneous dis-
tribution, which is fairly constant (Figs. 33 and 34).
NERVES OF THE UPPER EXTREMITY
The Musculocutaneous (External Cutaneous Nerve).-The cutaneous
portion winds around the outer border of the tendon of the biceps, and,
piercing the deep fascia, becomes Superficial, passing behind the median
cephalic vein; it divides opposite the elbow-joint into anterior and
posterior branches. &
The anterior branch descends along the radial side of the fore-
arm as far as the ball of the thumb, giving off cutaneous branches to
this region back of the wrist and carpus; at the wrist-joint it is placed
in front of the radial artery.
The posterior branch passes along the back part of the radial
side of the forearm, supplying this region as far as the wrist.
The internal cutaneous nerve pierces the deep fascia with the basilic
vein about the middle of the arm, and, becoming cutaneous, divides
into anterior and posterior branches. The anterior branch descends
usually in front of, but occasionally behind, the median basilic vein,
and is distributed to the skin on the anterior part of the ulnar side of
the forearm as far as the wrist.
The posterior branch passes obliquely downward and backward
over or in front of the internal condyle to the posterior surface of the
inner side of the arm, and is distributed to the skinas far as the wrist.
The lesser internal cutaneous nerve pierces the deep fascia on the
inner side of the brachial artery at the middle of the arm, and is
distributed to the skin on the inner and posterior surface as far as
the elbow.
The median nerve, at the bend of the elbow, lies beneath the
bicipital fascia to the inner side of the tendon of the biceps, separated
from it by the brachial artery. It passes between the two heads of
pronator radii teres, and it is deeply situated until about 2 inches
above the wrist, when it becomes superficial, lying between the
tendon of the flexor sublimis and flexor carpi radialis beneath or
slightly to the ulnar side of the tendon of the palmaris longus, and
follows this course into the hand.
This nerve can be easily reached by an open dissection at the bend
of the elbow for an intraneural injection, or by passing a needle be-
neath the tendon of the palmaris longus above the wrist for a para-
neural injection. In the hand this nerve supplies the Superficial
muscles of the thumb, two outer lumbricales, both sides of the thumb,
THE UPPER AND LOWER EXTREMITIES 225
index, and middle fingers, and radial side of the ring finger on their
palmar aspect; each digital nerve opposite the base of the first phalanx
gives off a dorsal branch which joins the dorsal branch from the radial,
and runs along the side of the dorsum of the finger to end in the
skin over the last phalanx.
The ulnar nerve, at the bend of the elbow, lies against the bone
between the internal condyle and olecranon, and is easily reached in
this position for a paraneural injection by passing the needle down
to it through the skin. In the forearm the nerve is deeply situated,
but becomes more Superficial near the wrist, lying to the radial side of
the tendon of the flexor carpi ulnaris covered by the skin and fascia,
where it can be fairly easily reached by a needle for paraneural injec-
tions. w
In this position the ulnar artery lies to the radial side and slightly
more superficial than the nerve, and is to be carefully avoided by
keeping the needle nearer the tendon of the flexor carpi ulnaris;
the injection should be made sufficiently free to permit some of the
solution reaching the artery upon which the palmar cutaneous branch,
given off higher up in the arm, descends to the skin of the palm.
The injection should be made about 2 inches above the wrist, to
reach also the dorsal cutaneous branch which is given off in this
position, and curves around the wrist beneath the tendon of the
flexor carpi ulnaris, to divide into branches to be distributed to the
inner side of the little finger and adjoining sides of the little and ring
fingers; if the injection is made too low these branches will escape.
The nerve continues down on the outer side of the tendon of the
flexor carpi ulnaris to its attachment to the pisiform bone, and im-
mediately beyond divides into Superficial and deep palmar branches.
The superficial branch supplies the palmaris brevis and skin on the
inner side of the palm, sending digital branches to the inner side of
the little and adjoining sides of the little and ring fingers. The deep
palmar branches supply the deep muscles of the palm.
The musculospiral nerve appears at the bend of the elbow after
piercing the external intermuscular septum, and descending between
the brachialis anticus and Supinator longus to the anterior surface
of the external condyle, where it divides into the radial and posterior
interosseous nerves. In addition to these terminal branches there
are three cutaneous branches: an internal cutaneous, which is dis-
tributed to the arm above the elbow, and is not of much concern to us
here, as all of these nerves should be reached by blocking the brachial
plexus above the clavicle.
15
226 LOCAL ANESTHESIA
The upper and smaller branch passes to the front of the elbow,
lying close to the cephalic vein, and is distributed to the skin on the
anterior surface of the arm; some fibers from this nerve may descend
below the elbow.
The lower branch is the more important to us here, and its posi-
tion should be borne in mind in all nerve-blocking operations at the
elbow. It pierces the deep fascia below the insertion of the deltoid,
running down along the outer side of the arm and elbow, then along
the posterior surface of the radial side of the forearm as far as the
wrist.
The radial nerve passes down the arm from the bend of the elbow,
lying beneath the supinator longus to the outer side of the radial
artery; about 3 inches above the wrist it turns outward, passing
beneath the tendon of the supinator longus, pierces the deep fascia
on the outer border of the forearm, and becomes superficial. In this
position it gives off its digital branches, an external branch which
descends to the radial side of the thumb, and an internal branch
which divides into three digital branches to supply the adjoining
sides of the thumb and index-finger, index- and middle fingers, and
the adjacent sides of the middle and ring fingers.
This nerve can best be reached for a paraneural injection about 2
inches above the wrist to the outer side of the tendon of the supina-
tor longus, making the injection into the deep fascia and carrying it
across the outer border of the forearm for about an inch, to insure
reaching all branches of the nerve.
The above is a brief review of the nerve-supply of the forearm
and hand which concerns us in the regional anesthesia of these parts.
It can be seen from a study of the points at which these nerves
are accessible, the opportunities offered for blocking them either by
direct exposure and intraneural injection or through paraneural in-
jection by directing the needle down to the positions in which the
nerves will be found. But the possibilities here of an occasional
anomalous distribution must also be remembered. For all operations
below the elbow, including forearm, wrist, and hand, the intraneural
method of blocking at the elbow the three principal nerve-trunks in
this region—radial, ulnar, and median—after free exposure by open
dissection, as first practised by Dr. Matas, will produce a perfect
anesthesia of all distal parts where the technic has been properly
carried out. It must, however, be remembered that, in addition to
the three above-mentioned nerves, the skin of the forearm is sup-
plied by the internal and external cutaneous nerves, and if account is
THE UPPER AND LOWER EXTREMITIES 227
not taken of these in making the injection the resulting anesthesia
will be imperfect or unsatisfactory.
The musculocutaneous nerve at the bend of the elbow passes
behind the median cephalic vein, then divides into anterior and poste-
rior branches. The anterior branch of the internal cutaneous passes
in front of or behind the median basilic vein, at the bend of the elbow,
its posterior branch passing over the inner condyle.
On account of the existence and position of the above cutaneous
nerves the infiltration done at the bend of the elbow to expose the
three principal nerve-trunks—radial, ulnar, and median—should be
made in an oblique or transverse course, and not vertical over the
Course of the large trunks, unless it should be preferred to inject the
lateral Subcutaneous tissue by a separate injection. In exposing the
radial in the groove between the brachialis anticus and supinator
longus, if the infiltration is carried in toward the middle line in the
neighborhood of the median cephalic vein, it will include in the anes-
thetic atmosphere the external cutaneous nerve.
It must also be remembered in injecting the radial not to omit
the posterior interosseous nerve, which is found in the substance of the
supinator brevis. The infiltration to expose the median nerve will
probably reach and anesthetize the anterior branch of the internal
cutaneous which lies under the median basilic vein, but, to be sure
that this nerve as well as the posterior branch have been reached
by the solution, it is advisable to inject a few small syringes of solution
subcutaneously between the median nerve and the internal condyle.
The ulnar nerve in thin and emaciated subjects, where it can be
readily felt, need not be directly exposed, but can be injected para-
neurally, but where overlaid by much tissue it is safer and more
surgical to directly expose it. In discussing this particular procedure
Prof. Matas, in his report on “Local and Regional Anesthesia” before
the Louisiana State Med. Soc., 1900, states the following:
“Personally, I regard the open intraneural method of cocainiza-
tion of the three nerves—musculospiral, median, and ulnar—at the
bend of the elbow as the most effective, certain, and simple means of
securing total anesthesia of the hand, wrist, and forearm.
“It is a strictly anatomic procedure which admits of no guess-
work, and for this reason is not likely to be popularized except in the
clinics of surgical specialists.
“The practicability of this method suggested itself to me in 1897,
but no opportunity presented itself for its application until January,
1898, when an old man, aged seventy-six, applied to my clinic for
228 . . . . . . . . . LOCAL ANESTHESIA
the relief of an extensive and deep epitheliomatous ulcer, which in-
volved a large part of the dorsal and hypothenar regions of the right
hand. The patient was profoundly arteriosclerotic, his radials were
hard and rigid as a pipe-stem, and his heart was the seat of loud aortic
and mitral murmurs, which indicated advanced valvular lesions.
He was a decidedly unfavorable subject for general anesthesia, and
I decided to anesthetize the hand by the direct neuroregional
method. -
“The musculospiral, the median, and the ulnar were readily and
painlessly exposed (under infiltration anesthesia, Schleich No. 1)
by separate incisions, made over the region of the individual nerve-
tracts, where they are most superficial at the bend of the elbow;
the nerves were then exposed, and each injected with 5 to 8 minims of
a 1 per cent. solution of cocain. This caused a slight fusiform Swell-
ing at the point of injection. .
“The wounds were sutured, but the threads were not tied, to
provide for further injection, and the entire region was protected by
a carefully applied aseptic dressing. The arm was then exsanguinated
by elevation, and the elastic constrictor was applied over the middle
of the arm. The anesthesia of the extremity was now complete from
the finger-nails up to the elbow. We were then able to extirpate the
growth very freely, including the fourth and fifth fingers with their
metacarpals and the corresponding palmar and dorsal aspects of
the hand, proceeding throughout with all the freedom that is per-
mitted by general anesthesia. After completing the work in the hand
the incision at the elbow was closed by tying the knots of the loose
catgut sutures, which had been purposely left untied before the
constrictor was removed. The operation was in this way not only
painless, but bloodless. Before the operation the patient was given
a hypodermic, consisting of # gr. morphin, 4%; gr. Strychnin, and T+5
gr. digitalin. -
“Since the first operation (January, 1898) was performed the
procedure has been repeated by myself several times and once by
my assistant, Dr. Larue. In all these cases the intervention was
necessitated by bone lesions of either the hand, wrist, or forearm.
“In all of these cases the patients were able to walk to their beds
after leaving the operating-table. None suffered from the least shock
or constitutional disturbance, and in none were the postoperative
sequelae such as to suggest that any injury had been done by cocainiza-
tion of the nerves. All the small wounds made to expose the nerves
healed kindly under the usual aseptic dressing. In all of these cases
THE UPPER AND LOWER EXTREMITIES 229
the anesthesia of the regions tributary to the nerves injected con-
tinued for a variable period, extending from ten to fifteen minutes
after the removal of the constrictor. . . . .
“In view of the practical success of this method of obtaining com-
plete insensibility of all the parts below the elbow, it is superfluous to
enumerate or discuss all the operations that can be performed in this
region without the help of general anesthesia. It is evident that in
absolutely anesthetic fields all operations are possible. . .
“I would again lay stress upon the fact that the method here
described is a regional method, in which the anesthesia is obtained
by the direct infiltration of the nerves at a distance from the field
of operation, and differs from all other methods suggested to accom-
plish the same regional object except that of Dr. Crile, of Cleveland,
Ohio, which is identical in principle and technic, except that it is
applied at a higher level by injecting the brachial plexus in the supra-
Clavicular space. . .
“At the time that my first operation was performed I was not
aware that very nearly the same results had been obtained by Reclus
Some time before the publication of his remarkable book, “La Cocaine
en Chirurgie,” in 1896. Reclus' operation differs, however, from
the one here described in the essential fact that he attacked the three
nerves at the elbow by subcutaneous paraneural injections. He
erroneously attributes the suggestion to Krogius, of Helsingfors, Fin-
land, and his results, though apparently satisfactory, were not
sufficiently encouraging to decide him to continue its further applica-
tion. In addition to his doubts as to the general reliability of this
method, he fears that traumatic neuritis may result from the direct
injection of the nerves, and also believes, very justly, that the intro-
duction of the needle in search for the nerves in the vascular sheaths
at the root of the limbs is fraught with too much risk to justify the
general adoption of this practice. We concur in these criticisms, as
they apply to the subcutaneous paraneural method, which is largely
a matter of approximation and guessing. These objections do not
hold, however, with the open intraneural method, in which the nerve
to be injected is directly exposed to view.
“As to the possibility of traumatic neuritis, which Reclus fears, I
have never noticed the least evidence or trace of it in the many cases
in which I have had an opportunity to practice this method in various
regions of the body. Le Fort (‘Soc. Centrale de Med. du Nord.,’ October
27, 1899, and ‘Gaz. des Hôpitaux,’ November 25, 1899) has also more
recently directed attention to the paraneural regional method and
23o LOCAL ANESTHESIA
applies it at the elbow and wrist, just as Reclus, Manz, and Holscher
have done. He refers to DeSoutte's experiments with neural anes-
thesia in horses and expresses confidence in its value. He also ex-
presses a theoretic fear of neuritis from trauma of the nerves by direct
injection, but this fear, as I have stated, is unfounded. I do not doubt
that the subcutaneous paraneural method is a feasible procedure,
and will yield satisfactory results in emaciated, fleshless patients, in
whom the larger nerve-trunks are almost visible under the skin; in
such patients there should be no difficulty in reaching the immediate
vicinity of the nerves, or the nerves themselves for that matter, since
they are practically exposed to view. It is also in just such patients
that the Schleich’s general infiltration anesthesia will find a suc-
cessful application. Not long since Dr. Gessner reported a case of
amputation of the arm above the elbow for tubercular arthritis of the
elbow-joint, in which the anesthesia was obtained with perfect success
by the Schleich infiltration method. Schleich, Reclus, and their
numerous followers have reported many cases of the same kind (vide
among other recent contributions).
“‘La Nacose et l'anesthesie locale par J. Richbon Kjamerund,
Bull. gen’l de Therap.,’ January 15 and 30, 1899; and T. Wieker-
hauser, “Operationen mit Schleichscher Anälgesie, Centralbl. für Chir.,’
October 21, 1899.
“In the earlier years of my experience with cocain I also performed
an amputation of the arm by Corning's infiltration for advanced tuber-
cular arthritis with excellent results; but these successes do not mean
that Schleich's infiltration method is applicable to all cases; it only
illustrates the advantage to be derived from the adoption of the
various methods of anesthesia to different conditions.”
Dr. Matas, in his previously mentioned report, in writing of the
hand and wrist, states the following:
“The anesthesia of these regions is obtained by any one of three
methods: (1) Direct infiltration (Schleich); (2) paraneural infiltra-
tion at the wrist (Reclus, Braun, Manz, Lefort); (3) regional direct
(open) intraneural infiltration at the elbow (Matas).” To these we
can now add the intravenous method of Bier and intra-arterial
anesthesia.
“The utility of the infiltration method is practically limited to
fractional areas of these parts, and can be applied successfully in the
evacuation of purulent collections, palmar abscesses, the removal of
well-defined tumors, warts, epitheliomata, etc., foreign bodies, the
extirpation of ganglions, etc. It has also proved sufficient in my prac-
THE UPPER AND LOWER EXTREMITIES 23I
tice, as in that of others, for the amputation of one or two fingers with
their metacarpals, but in all these the effectiveness of the infiltra-
tion will be very materially increased by a knowledge of the dis-
tribution of the cutaneous and deeper nerves supplying the area of
operation. Thus in resecting or disarticulating the metacarpals, the
infiltration is not only carried into the entire periphery of the bone,
including the periosteum, but the deep, adjoining interosseous nerves
must likewise be enveloped in a cocain atmosphere. When the
injuries or lesions are such that the operation is likely to be extensive,
irregular, or ill-defined, as, for instance, when several digits with their
metacarpals are to be amputated with a part of the palmar tissues,
a recourse to the neuroregional method at a higher level is preferable,
if not absolutely necessary, from the point of view of effectiveness
and simplicity. In anesthetizing the hand and wrist in its totality, the
radial, ulnar, and median nerves can be anesthetized by injecting the
anasthetizing fluid deeply into the perineural tissues along the well-
known anatomic paths of these nerves in the lower forearm, just
above the wrist, where they are known to be most superficial. This
procedure was first described and practiced by O. Manz (Kraske's
clinic; ‘Centralbl. f. Chirurg.,’ 1898, No. 7), by Holscher (“Muench.
Med. Wochenschr.,’ February 21, 1899), and by F. Berndt (“Muench.
Med. Wochenschr.,’ 1899, No. 27), and in their hands has yielded some
fairly good results. Holcher and Berndt, following Oberst and Braun,
apply an elastic constrictor I or 2 inches above the wrist, and inject
20 c.c. of a 2 per cent. cocain solution, distributed in the region of the
three nerve-trunks, and wait fifteen minutes, when the insensibility
of the entire hand will follow. But the paraneural method applied
in this blind subcutaneous fashion is, as Manz himself admits, an un-
certain and unsatisfactory procedure at best, and it is not likely to find
many adherents.”
THE FINGERS AND HAND
In the practice of regional anesthesia of the hand and fingers we
have many opportunities for blocking the nerve-trunks just above
the wrist by taking advantage of their superficial position and ex-
posing them by dissection for intraneural injection, or through para-
neural injections by passing the needle through the skin down to the
points where these nerves are to be found. The following experi-
ments, made by Prof. Heinrich Braun, of Zwichau, and given in his
book on “Die Lokal Anasthesie,” illustrates the possibilities of its
use here:
232 * . LOCAL ANESTHESIA
“Experiment I (June 18, 1898, Dr. B.). Firm constriction of the arm. Injection of
I c.c. of I per cent. tropococain solution 3 cm. above the wrist under the tendon of the
palmaris longus (Fig. 35). The constricting rubber band was now sufficiently loosened
to permit a marked stasis hyperemia of the arm. Fifteen minutes after the injection .
complete anesthesia of the distribution of the median nerve, as well as paralysis of the
short muscles of the thumb, was produced. The anesthesia remained fifteen minutes
after the removal of the constrictor. *
“Experiment 2 (May 14, 1902, Dr. B.). One-half cubic centimeter of 2 per cent. cocain
solution was injected at Io : 45, 4 cm. above the wrist under the tendon of the palmaris
longus; the arm was not constricted; at Io : 47 a feeling of tickling and warmth in the
first, second, third, and fourth fingers and palm of the hand; Io :55, complete anesthesia
on the flexor surface of the thumb, second and third fingers, and the radial side of the
fourth finger, in the palm of the hand a very marked depression of the sensibility in the
entire nerve territory, with a paresis of the thumb muscles; II : 25, sensation returned.
“Experiment 3 (Oct. Io, 1902, medical student, B.); II: 55, injection of I c.c. of 9%
per cent. cocain solution with 3 drops adrenalin around the median nerve above the wrist.
The arm was not constricted. After fifteen minutes the sensibility, as indicated in Fig. 33,
Nos. I and 2, almost completely disappeared; on the ball of the thumb, in the palm of
the hand, and on the flexor surfaces of the thumb and index-finger completely disappeared.
There was very pronounced paralysis of the short muscles of the thumb, and the skin
over the distribution of the median nerve was hyperemic, red, and showed increased tem-
perature, while the skin over the neighboring ulna distribution remained normal. The
sensibility returned about 2 o’clock, two hours after the injection.”
By taking advantage of the Superficial position of the radial
nerve just above the wrist, where it passes beneath the tendon of the
Supinator longus on the outer border of the arm, and making the in-
jection in a transverse manner at this point beneath the skin and
superficial veins, an anesthesia of its peripheral branches is obtained,
as illustrated by the following experiments:
“Experiment 4. . After constriction of the arm 134 c.c. of 34 per cent. cocain solution
was injected in the above manner. After five minutes anesthesia appeared, as indicated
in Fig. 36, Nos. 3 and 4.
“Experiment 5 (May 13, 1899, Dr. B.). The same experiment with 2 c.c. of 94 per
cent. tropocain solution with constriction of the arm resulted in an anesthesia of about
similar extent. .
“Experiment 6. Forms the continuations of experiment No. 3 on the same hand,
where previously the median nerve had been blocked, I c.c. of 3% per cent. cocain solution,
with the addition of 3 drops adrenalin solution (1 : Iooo) was now injected on the radial
nerve above the wrist. Fifteen minutes later the hand, as indicated in Fig. 33, Nos. 5
and 6, was completely insensible and remained so for about four hours.”
As mentioned by Braun in commenting upon this experiment, it is
not likely to be of much value alone except for very limited superficial
operations, but when combined with a simultaneous injection of the
median nerve it is a simple and effective means of anesthetizing the
entire radial side of the hand. Higher up in the forearm, at the junc-
tion of the middle and lower third on the outer border, where the
THE UPPER AND LOWER EXTREMITIES 233
intermuscular septum divides the flexor from extensor muscles, the
radial nerve is also fairly accessible, and may be successfully blocked
at this point by passing the needle vertically inward beneath the
supinator longus. The following experiment by Dr. Braun illustrates
the results obtained:
“Experiment 7 (May 2, 1902, Dr. D.). Twelve o'clock, an injection of I c.c. of 2 per
cent. cocain solution in the above-described way, the needle had exactly met the nerve-
trunk, as indicated by the radiating paresthesia. No constriction. Immediately after
the injection occurred a marked radiating paresthesia and sense of warmth in the thumb.
12 : Io, complete regional anesthesin of the nerve; anesthesia of the skin is indicated, as
in Fig. 34, No. 2. Motor paralysis of the radial. After forty minutes sensibility and
motility returned.
The ulnar nerve is accessible, either for exposure by dissection
and intraneural injection or for paraneural injection, above the
M interosseus dor:r
3% §2/radialis
g º == º: zº -
Aulnaris .º &= oº.
& & tºº § A. radia/is
M/?exor ra’azalis
e M medianus
Mflexor ulnares
M/oalm. Cong.
Fig. 35.-Cross-section through forearm three fingers-breadth above pisiform bone.
(From Braun.)
wrist-joint, preferably three or four fingers' breadth above to insure
reaching the posterior branch, which may be given off this high up.
In this position the nerve lies between the tendon of the flexor carpi
ulnaris and the ulnar, as shown in Fig. 35, and is best reached for
paraneural injections by introducing the needle from the ulnar side
between the tendon and the bone in the direction indicated by the
arrow. It is rather unsafe and inadvisable to attempt to reach it from
in front (except by dissection) on account of the proximity of the ulnar
vessels, which here lie slightly more superficial than the nerve and
slightly to the radial side. Figure 36, VII and VIII, indicate the extent
of the resulting anesthesia after an injection of I c.c. of a o.5 per cent.
cocain solution with 3 drops of adrenalin (I: Tooo) as practiced by
Braun in the above-mentioned way. It may, however, be easier and










234 LOCAL ANESTHESIA
preferable, instead of injecting the nerve at this point to reach it back
of the internal condyle. In thin subjects, where the nerve can be
readily felt, a paraneural injection may be undertaken by first locating
the nerve between the thumb and finger of one hand while making the
injection with the other; the inferior profunda artery, which lies in
this position, is more deeply situated in the muscle just over the
bone. The following experiments by Braun illustrates the result ob-
N
( \
Fig. 36.-Resulting areas of anesthesia of hand and fingers from subcutaneous and
paraneural injections. (From Braun.)
tained, while Experiment 9 is a paraneural injection of the ulnar and
median nerves above the wrist:
“Experiment 8 (May 13, 1902, Dr. L.). 12 : 50 o'clock injection of I c.c. of 2 per cent.
cocain solution in the previously mentioned way. No constriction. Immediately pares-
thesia and sense of warmth as far as the ends of the fourth and fifth fingers. After six
minutes complete regional anesthesia of the skin occurred, as indicated in Fig. 37, I.
Sensibility returned fifty minutes after the injection.
“Experiment 9 (Dec. 9, 1902, medical student). One cubic centimeter of 1 per cent.
cocain solution with 3 drops of adrenalin solution was injected three fingers' breadth above
the wrist on the ulnar and median nerves. After twenty minutes anesthesia appeared
in the territory, as indicated in Fig. 36, IX and X. The sensibility returned after four
hours in the ulnar territory and after five hours in the median.”

THE UPPER AND LOWER EXTREMITIES 235
Experiment 1o represents the results of a linear injection made
subcutaneously from the region of the radial artery across the back of
the wrist to the pisiform bone.
“Experiment Io (Feb. Io, 1899, Dr. B.). Three cubic centimeters of 1 per cent. cocain
solution was injected in the previously mentioned way in the arm after constriction.
After five minutes anesthesia appeared in the territory, as indicated in Fig. 36, XI and
XII. Twenty minutes after removal of the constriction sensibility returned,
“Experiment II. Five cubic centimeters of 2 per cent. cocain solution was injected
in a line across the extensor surface of the forearm, 6 cm. above the head of the ulna.
-
Fig. 37.-Resulting areas of anesthesia of arm, hand, and fingers from subcutaneous
and paraneural injections. (From Braun.)
The arm was not constricted. After fifteen minutes anesthesia appeared, as indicated in
Fig. 37, III. A transverse subcutaneous injection was made on the flexor side of the
wrist, which resulted in an anesthetic field being produced, as shown in Fig. 37, IV.
It is clear from a study of the picture that only the more superficial cutaneous branches in
the immediate neighborhood were effected, and none of the deeper branches.”
The result of a circular subcutaneous injection above the middle
of the forearm is shown by Braun in Fig. 37, WI; 8 c.c. of a o.5 per
cent. tropacocain solution was used, the forearm being constricted.
The anesthesia, as indicated in the shaded area, was complete in



236 LOCAL ANESTHESIA
ten minutes. The following experiments are also of interest. In com-
menting upon experiment No. 15, Braun states that he has often
employed this method for opening and excising an inflamed bursa
over the olecranon:

Fig. 38.-Resulting areas of anesthesia from subcutaneous infiltration of forearm.
(From Braun.)
“Experiment 13 (Dr. B.). Four cubic centimeters of 94 per cent. cocain solution with
8 drops of adrenalin solution, 1 : Iooo, was injected in a continuous subcutaneous line,
which began posteriorly over the olecranon and extended laterally over the external
condyle to the middle of the biceps tendon in front. It required twenty-five minutes for
anesthesia to be produced, as indicated in Fig. 38, III. The anesthesia then remained
several hours.
“Experiment 14 (Dr. P.). Four cubic centimeters of o.5 per cent. cocain solution with 8
drops of adrenalin, I : Iooo, was injected in a subcutaneous line, which began over the ole-
s— - -
-
/ | V 17
cranon posteriorly and extended over the internal condyle to the middle of the biceps
tendon. After thirty minutes the anesthetic area, as indicated in Fig. 38, IV, appeared.
In the lower half of the forearm, as in the preceding experiment, the anesthesia was not
complete. -
“Experiment 15 (Dec. 12, 1902, Dr. L.). Four cubic centimeters of o.5 per cent. cocain
solution with 8 drops of adrenalin solution, 1 : Iooo, was injected in a subcutaneous line,
beginning over the internal condyle and extending in a curve over the posterior surface of
the arm and ending over the belly of the supinator longus at the external condyle. After
fifteen minutes the anesthetic area, as indicated in Fig. 38, II, was complete. Deep
needle sticks over the olecranon and over the posterior surface of the ulna showed that the
periosteum was also insensible. -
“Experiment 16 (Nov. 1, 1902, Dr. B.). Four cubic centimeters of o.5 percent. cocain
solution with 8 drops of adrenalin, I : Iooo, was injected subcutaneously in a line which
began over the internal condyle and extended deeply across the bend of the elbow to ter-
THE UPPER AND LOWER EXTREMITIES 237
minate over the belly of the supinator longus. The veins were avoided without difficulty,
passing the needle under them. After thirty minutes the area, as indicated in Fig. 38,
I, also almost the entire flexor surface of the forearm and a part of the extensor surface
had become anesthetic. The injection was made at 12 o'clock, and about 4 o'clock in
the afternoon sensation returned.”
Anesthesia of a part of a finger can be obtained by direct local
infiltration; more often the anesthesia of an entire finger is necessary,
especially in inflammatory affections (bone felons, panaritium, teno-
synovitis, traumatism, foreign bodies, etc.). In all such cases the para-
neural infiltration method applied at the root of the fingers will yield
perfect results. This is the method which we have continuously
followed in our practice. If, for example, it is a bone felon that we wish
to open, the skin of the root of the finger, a little above the level of the
palmar web, is infiltrated on the dorsal side (Fig. 39); a fine hypo-
dermic needle is used for infiltration, and a wheal of intracuticular
Fig. 39.—Cross-section of finger: a, Flexor tendon; b, bone; c, extensor tendon; I and
2, points of entrance of needle to reach dorsal and palmar nerves. (From Braun.)
edema serves as the starting-point from which a circle of anesthesia
is carried around the base of the digit. After this has been done, the
needle is driven in painlessly through the infiltrated skin into the
lateral aspect of the finger in search of the digital nerves, which lies on
each side of the phalanx in close proximity to the blood-vessels; a few
drops (5 to Io) of strong solution of novocain (o.5 per cent.) are in-
jected into the paraneural regions so as to create an anesthetic at-
mosphere around the nerves.
The arm is now raised and the finger is exsanguinated by gravity,
after which the circulation is arrested by applying a narrow elastic
band around the finger, just above (centrad of) the ring of infiltra-
tion. In a few minutes the finger will be “numb,” and will bear
any operation that may be required in any part of the digit.
“In inflammatory affections the action of the anesthetic will be
intensified by injecting the solution warm in order to favor its diffusion

238 LOCAL ANESTHESIA
(Corning, Tito-Costa, Hackenbuch). After the constrictor had been
applied and the limb has assumed a cadaveric appearance, the ap-
plication of ice-cold water, or ethyl chlorid spray, for a few minutes to
the finger will hasten and greatly intensify the anesthetic effect. This
is particularly true of acute inflammatory conditions, which are the
most rebellious to local anesthetic influences. If the anesthesia is
retarded we should be in no hurry to add more anesthetic. The best
plan is to relax the constrictor, allow the circulation to return, and
diffuse the anesthetic for half a minute, and again exsanguinate and
constrict the digit. The elastic constrictor combined with exsanguina-
tion is not only valuable in prolonging the anesthesia indefinitely, but
it helps to intensify it as well. In fact, it is possible by simple ex-
sanguination and prolonged elastic compression at the root of the
finger and limbs to produce a degree of anesthesia which is itself
Fig. 4o.—Areas of digital anesthesia resulting from tranverse subcutaneous infil-
tration on dorsal and palmar surfaces. Compare with nerve distribution, shown in
Fig. 41. (From Braun.)
compatible with the painless performance of small and superficial
operations. (This fact, long ago utilized by James Moore, 1784, and
by Hunter, has been especially insisted upon in recent times by Corn-
ing, Kauffman, Kummer, and every surgeon who has had experience
with it.) The paraneural method which we have described is simply
a regional application of Corning's principles (1885)” (Matas).
“In Germany it is known as Oberst's method, the only difference
between his method and Oberst's consisting in the fact that Oberst
applies the constrictor first; it is also referred to by some writers as
Kummer's (1886) and Kroguis’ (1896) method, but the principles
of the method are really of American origin, and began with the
experiments of Hall and Halsted (1884) and Corning (1885).
“An effort has been made in some quarters to establish an an-

THE UPPER AND LOWER EXTREMITIES 239
tagonism between Schleich's method and the paraneural regional
method, as here described, but this, as Briegleb and others have
shown, is not really true. Schleich's infiltration method, as applied
to the anesthesia of a finger or toe, is a regional method, since he com-
nervus digitalis dorsalis
- arteria digitalis
2' dorsalis
digitalis volaris
proprius
*
arteria digitalis
volaris propria
arteria digitalis
vularis rommunis
Fig. 41.-A lateral view of the nerves and vessels of the index-finger. (Sobotta and
McMurrich.)
pletely edematizes the circumference of the finger at its base and thus
controls the entire nerve-supply of the digit. The regional method
simply accomplishes the same results in a more economic manner,
Fig. 42.-Points of injection and lines of infiltration in operating upon fingers and
hand. (From Braun.)
the solutions being more concentrated in percentage and injected in
direction of the nerve-tracts, thus avoiding the complete edematiza-
tion of the tissue that is necessary in using Schleich's weaker solu-
tions” (Matas).







24o LOCAL ANESTHESIA
Figure 4o illustrates the results of a subcutaneous injection made
on the palmar surface of the middle finger and the dorsal surface
of the index-fingers, in each case making the injection deep enough to
reach the corresponding digital nerves. It illustrates beautifully the
Fig. 43-Points of injections and lines of infiltration for anesthetizing two or more
fingers. (From Braun.)
distribution of the digital nerves, the palmar digital nerves supplying
the entire palmar surface and the dorsal surface of the last phalanx,
the dorsal digital nerves reaching only as far as the middle phalanx.
-
Fig. 44.—Points of injections and lines of infiltration for resecting part of hand.
(From Braun.)
The disparity in the two shaded areas represents the overlapping of the
fields of the two nerves (Fig. 41).
A study of Figs. 42-46 will suggest the further application of
regional methods to the base of one or more fingers and parts of the
hand, the large dots indicating the points at which the nerves are to


THE UPPER AND LOWER EXTREMITIES 24I
be reached by subcutaneous injection for paraneural infiltration, the
dotted lines marking the course for intradermal infiltration. As the
nerves in the hand are all small it is practicable to use Solution No. 1
Fig. 45–Points of injections and lines of infiltration for anesthetizing abscess at base
of fingers. (From Braun.)
throughout, but, if preferred, the paraneural or deep injections can
be made with o.5 per cent. novocain solution, using Io to 20 minims
about each nerve. It is evident that in extensive resections of the
-
Fig. 46.-Points of injections and lines of infiltration for resecting digits or part of
hand. (From Braun.)
hand it is preferable to resort to regional anesthesia at the elbow or
above the wrist, rather than resort to too extensive infiltrations in this
region.


16
242 LOCAL ANESTHESIA
THE LOWER EXTREMITY
“What has been said of the upper extremity may be, in a great
measure, repeated in regard to the lower limbs. The general prin-
ciples and methods are the same, except that they vary in their topo-
graphic application. The infiltration, the paraneural infiltration, and
the regional (open) intraneural methods can all be utilized with ad-
vantage according to the regions involved and the local and consti-
tutional indications furnished by the patients themselves.
“The infiltration method with weak solutions, according to
Schleich, with or without constriction, and the mixed infiltration-
neural methods are alone able to meet a vast number of indications.
The surgery of the toes and of their metatarsals and limited areas of the
soft parts, including the ligations of all vessels of the lower extremity
from the external iliac (R. N. Hartley, Leeds, 1895) to the dorsalis
pedis, can be made subservient to the infiltration method. In our own
practice we have notes of cases of ligation of the superficial femoral
at Scarpa's triangle, of the anterior and posterior tibial (in one case a
traumatic aneurysm of the middle third), and of the anterior tibial,
in which these operations were performed with infiltration on the
Corning plan. We have repeatedly extirpated the varicose saphenous
vein from the groin to the knee, and performed Sonnenburg's opera-
tion for varicose veins by ligation and partial excision of the internal
and external saphenous with simple infiltration anesthesia. Infiltra-
tion is also sufficient for opening abscesses, including large, diffuse,
purulent collections; in draining joints; in the extraction of foreign
bodies; in the removal of tumors, and in the excision of ulcers of moder-
ate size. It is particularly valuable in making all variety of exploratory
incisions to clear up doubtful diagnosis, etc. As early as 1888 I was
able to extirpate a subperiosteal sarcoma of the femur in a very thin
subject. Josiah Roberts, of New York, was able to perform a femoral
supracondyloid osteotomy (Macewen's operation for genu valgum) in
a boy four years old, and an excision of the hip (the head of the femur
being removed below the great trochanter) in a child six years of age
by the same procedure. These operations were performed by Corn-
ing's method as early as 1885, a 5 per cent. cocain solution being used
(‘New York Med. Jour.,’ October 24, 1885). Varick, by utilizing the
same technic, successfully amputated the thigh in 1886 (“New York
Med. Jour.,’ vol. x, No. III).
“Trapani was also one of the first to report an amputation of the
thigh by Schleich's method (vide Alessandri's reports on anesthesia
to the Italian Surgical Society, Transactions for 1897). Schleich and
THE UPPER AND LOWER FXTREMITIES 243
his followers, Rhodes (of California), Cowan, and others, were among
the earliest to report instances of amputation of the leg by simple
infiltration, and Wilkerhauser (“Operationen mit Schleichscher
Anâlgesie,’ abstract, “Centralbl. f. Chir.,’ October 21, 1899, No. 42)
reports 18 extensive bone operations out of a list of 113 major opera-
tions done by this method, in which the sections of the thigh and leg
bones were required. All of these earlier reports, which can now be
multiplied many hundred times, simply confirm the statement pre-
viously made that it is necessary to exercise judgment in the adaptation
of the various methods of local and regional anesthesia to special con-
ditions. The operator should not be wedded to any single method,
but knowing the capabilities of each can select his technic and, at
times, obtain surprising results with a method that would appear to the
inexperienced as theoretically inadequate to meet the demands of
the case” (Matas).
“But, in spite of the numerous interventions on the lower limbs
which have been obtained by simple infiltrations with the Corning
or Schleich methods, it must be recognized that these successes have
been (with the notable exception of the toes) more conspicuous by
their rarity than by their frequency. They simply illustrate what
can be done with the method in exceptionally favorable conditions,
both as regard to the morale of the patient and the favorable ana-
tomic condition of the parts. This is particularly true of all extensive
operations involving the skeleton of the foot, leg, and thigh in robust,
fleshy subjects. In this class of patients local anesthesia is, as a rule,
inadequate, and when an excision of a large joint (the ankle or knee),
or when a large sequestrotomy, ostectomy, or an amputation is con-
templated, a method more positive and reliable is required to accom-
plish the intervention with that freedom of action that can only come
from absolute analgesia. It is precisely under such circumstances,
and when the contra-indications to general anesthesia are positive,
that the regional intraneural method can be confidently appealed
to” (Matas).
The Nerve-supply of the Lower Extremity.—The inguinal region
receives its nerve-supply from a variety of Sources which are not
capable of being dealt with collectively by regional methods; Con-
sequently, all operative procedures here should be done under infil-
tration.
The external cutaneous nerve emerges from the pelvis, close to the
anterior superior spine of the ilium, beneath Pouparts' ligament.
In thin subjects it is easily reached in this position or just below it by
244 LOCAL ANESTHESIA
a paraneural injection. The anterior branch of this nerve emerges
from beneath the fascia lata, about 4 inches below Poupart's ligament,
and becomes subcutaneous, supplying the skin on the anterior and
outer side of the leg as far as the knee. - -
The posterior branch curves backward and supplies the skin
on the outer and posterior aspects of the thigh as far as the middle
of the limb.
Dr. Hugh Young was one of the first to utilize paraneural injec-
tions of this nerve to obtain skin-grafts from the outer side of the
thigh. -
The obturator nerve enters the thigh through the upper part of the
obturator foramen and divides into anterior and posterior branches,
which are separated from each other by fibers of the obturator ex-
ternus and adductor brevis muscles. The anterior branch passes
down behind the pectineus and adductor longus and communicates
with the internal cutaneous and internal saphenous nerves, forming a
plexus around the femoral artery, which descends on this vessel to
near the knee-joint; occasionally this communication furnishes a cuta-
neous branch to the thigh and leg; when this occurs this nerve passes
beneath the adductor longus and Sartorius muscles and becomes super-
ficial at the inner side of the knee, communicating with the long
saphenous nerve, and is distributed to the inner side of the leg as low
as its middle. When this branch is absent its place is supplied by the
internal cutaneous. The posterior branch Supplies the adductor
muscles, and sends a branch to the knee-joint which descends upon the
popliteal artery to the back of the joint. º
The deep position of the obturator nerve where it enters the thigh,
and its occasional contribution to the cutaneous nerve-supply of the
leg, makes this nerve often a troublesome factor in the regional anes-
thesia of the lower extremity.
The anterior crural nerve emerges from beneath Poupart's ligament,
lying on the outer side of the femoral artery; it immediately divides
into an anterior and posterior set of branches, which are separated
by the external circumflex vessels.
The middle cutaneous, from the anterior division of the crural,
becomes Superficial about 3 inches below Poupart’s ligament by pierc-
ing the fascia lata; it divides into two branches, which descend on the
front of the thigh supplying the skin as far down as the knee.
The internal cutaneous nerve, from the anterior division of the crural,
passes obliquely across the upper part of the sheath of the femoral
artery, and divides in front or at the inner side of that vessel into
THE UPPER AND LOWER EXTREMITIES 245
anterior and posterior branches. The anterior branch passes down
on the Sartorius muscle and perforates the deep fascia at the lower third
of the thigh, and is distributed to the skin of this region and the inner,
anterior, and outer surfaces of the knee. The posterior or internal
branch pierces the fascia lata on the inner side of the knee in front
of the Sartorius tendon, and is distributed to the skin on the inner side
of the leg.
The internal or long Saphenous nerve, from the posterior division
of the anterior Crural, approaches the femoral artery beneath the
Sartorius muscle, lying first in front and then on the inner side of
this vessel; continuing down with it in Hunter's canal, it becomes
Superficial by piercing the deep fascia on the inner side of the knee
between the tendons of the Sartorius and gracilis muscles; it then
descends along the inner side of the leg in company with the internal
Saphenous vein, lying just behind the inner border of the tibia, dis-
tributing branches to the inner and anterior aspects of the leg, and
terminates by passing in front of the internal malleolus, to be dis-
tributed to the skin on the inner side of the foot as far forward as the
great toe.
The small sciatic nerve descends beneath the pyriformis muscles
with the great Sciatic, lying slightly to the inner side of the latter; the
perineal and pudendal branches curve upward to these regions, while
the femoral cutaneous branches pass down the back of the thigh to
Supply the skin as far down as the back of the leg.
The great sciatic nerve descends into the thigh beneath the pyri-
formis muscle, lying midway between the tuberosity of the ischium and
the great trochanter, and passes down to about its lower third, where
it divides into internal and external popliteal nerves; this division
may, however, take place at any part of its course from the pelvis
down, and should be borne in mind in injecting this nerve high up to
insure getting both trunks.
The internal popliteal, the larger of the two branches, descends
along the back part of the thigh and middle of the popliteal space,
lying first on the outer side of the artery, then crossing behind it to its
inner side and passing with it beneath the arch of the soleus, when
it becomes the posterior tibial.
The posterior tibial nerve, deeply situated above, becomes more
superficial lower down, where it is covered by the skin and fascia; in
the lower third of the leg it lies just internal to the margin of the
tendo achillis; in the interval, between the malleolus and the heel, it
lies external to the artery against the posterior surface of the tibia
246 LOCAL ANESTHESLA
and about 1 cm. internal to the tendo achillis; in this position it is
readily accessible for paraneural injections. Lower down in this
space the nerve divides into internal and external plantar branches.
The internal branch supplies the sole and inner side of the foot and
gives off digital branches to the inner side of the big toe, adjoining
sides of the big and second toe, second and third and fourth toes. It
will be observed that the distribution of this nerve is almost identical
to the distribution of the median in the hand, the digital branches
giving off dorsal cutaneous branches at the base of the toes in the
same manner as occurs in the hand.
The external plantar nerve supplies the outer side of the foot,
little toe, and adjoining side of the fourth toe, together with deep
muscles of the foot, closely corresponding to the distribution of the
ulnar in the hand.
The external popliteal or peroneal nerve descends close along the
inner margin of the biceps tendon on the outer side of the popliteal
space; it then passes between the tendon of the biceps and outer
head of the gastrocnemius muscle and curves around the head of the
fibula, where it can be readily felt, and is again accessible for ex-
posure or for paraneural injection; it then descends into the substance
of the peroneus muscles. The cutaneous branches from this nerve
supply the skin of the back part and outer side of the leg as far down
as the heel. In the substance of the peroneal muscles this nerve
divides into anterior tibial and musculocutaneous branches.
The anterior tibial nerve is deeply situated in the upper part of its
course, but becomes more superficial near the ankle, lying to the
outer side of the dorsalis pedis artery and between the extensor pro-
prius hallucis and the extensor longus digitorum; at this point, just
above the annular ligaments, it is fairly accessible for exposure and
direct injection or for paraneural injection after locating the dorsalis
pedis pulse by passing the needle down to the deep fascia just external
to the artery; however, it would be preferable in making a paraneural
injection to do so higher up, where the peroneal nerve winds around
the head of the fibula, thus reaching the anterior tibial and muscular
cutaneous distribution. At the ankle-joint the nerve divides into an
internal and an external or tarsal branch. The internal branches
supply the adjoining sides of the great and second toes. The external
branch supplies the adjoining sides of the second, third, and fourth
toes and extensor brevis muscles.
The musculocutaneous nerve becomes superficial at the lower
third of the leg by passing forward between the peronei muscles
THE UPPER AND LOWER EXTREMITIES
247
Fig. 47.-Cutaneous nerve-supply of
the lower extremity (anterior view): A,
Genitocrural; B, ilio-inguinal; C, external
cutaneous; D, middle cutaneous; E, inter-
nal cutaneous; F, lateral cutaneous of
peroneal; G, internal saphenous; H, ex-
ternal saphenous; I, musculocutaneous;
J, external plantar; K, internal plantar;
L, anterior tibial. (Campbell.)
Fig. 48.-Cutaneous nerve--supply of
the lower extremity (posterior view): A,
Small sciatic; B, internal cutaneous; C,
external cutaneous; D, lateral cutaneous;
E, internal saphenous; F, external saph-
enous; G, musculocutaneous; H, internal
calcaneus. (Campbell.)


248 LOCAL ANESTHESIA
and extensor longus digitorum; in this position it can be reached by
a subcutaneous injection, made across the lower portion of the leg
at this point, over the tendons of the above muscles. As the nerve
descends it divides into two branches, an internal, which passes
over the front of the ankle-joint and Supplies the inner side and dorsum
of the foot, inner side of the great toe, and adjoining sides of the
second and third toes. The external branch Supplies the skin on the
outer side of the foot and ankle, and the adjoining sides of the third,
fourth, and fifth toes (Figs. 47, 48).
A study of the above nerve-supply, with an observance of the
points at which the nerve-trunks and their principal branches are
accessible, will suggest many opportunities for the practice of regional
anesthesia. The following operative procedures are a fairly thorough
review of the surgical possibilities.
Scarpa's Triangle.—All superficial operations here can be readily
done under infiltration, from the simple incising of a suppurative
bubo to the removal of the entire superficial group of glands. Where
the deep group are involved, requiring dissections beneath the fascia
lata, a general anesthetic should if possible be used.
In operating here it is preferable to complete the entire infiltra-
tion before making the incision, as it is difficult to anesthetize the dif-
ferent planes of tissue after they have been divided, as the solution
runs out as fast as injected. The infiltration had best be done on the
Hackenbruch plan, by first encircling the mass by a line of intradermal
anesthesia; the needle is then passed from this line into the deeper
tissues, all around and under the mass of glands, thus completely
enclosing them within a wall of anesthesia (Figs. 19–49). Solution
No. 1 and a few drops of adrenalin to the ounce is used; after a few
minutes' delay allowed for thorough saturation of the tissues the
operation may be begun, and should be entirely painless. Where the
deep glands are involved, and it is necessary to go below the fascia
lata, the different tissues should be infiltrated as the operation ad-
vances, but this procedure here may sometimes prove difficult. Care
should be observed to bear in mind the position of the vessels, and
when infiltrating in a doubtful region to make the injection only
when advancing or withdrawing the needle.
Other tumors of this region can be removed in the same way.
It is also quite a simple matter to ligate and divide the upper end of the
long Saphenous vein for varicosities of the leg, as in the Trendelenburg
operation, or the entire vein can be removed by a progressive anes-
thesia extending from above downward.
THE UPPER AND LOWER EXTREMITIES 249
The removal of skin-grafts is quite easily performed from the
antero-external aspect of the thigh, the usually selected site, either
by direct intradermal infiltration of the entire area, from which the
grafts are to be removed (this intradermal edematization of the skin
greatly facilitates their removal without apparently affecting the
vitality of the grafts), or by a paraneural injection of the external
cutaneous nerve, where it emerges from beneath Poupart's ligament
close to the anterior superior spine, as first practiced by Dr. Young of
Johns Hopkins. For this injection the needle is best entered from the
Fig. 49–Shows method of infiltrating base of bubo area by passing needle obliquely down-
ward and inward after embracing area within circle of cutaneous anesthesia.
outer side and penetrated to a sufficient depth to reach beneath the
fascia lata, under which it is advanced, depositing 2 drams of about a
o.5 per cent. Solution of novocain in the recognized position of the
nerve. Anesthesia should set in after a few minutes, and be suffi-
ciently extensive to allow of a fairly liberal removal of tissue.
The removal of varicose veins of the leg need no special descrip-
tion, as it is best done through infiltration. Any of the accepted
procedures may be easily carried out by local anesthesia (except
stripping of the vein, which will be difficult by this method), the
multiple incisions with ligation and division of the vein or resection

25o LOCAL ANESTHESIA
of parts. The Schede operation, or the entire removal of the vein
from the saphenous opening to the ankle, have all been practiced by
us with perfect satisfaction.
THE HIP AND THIGH
“Regional anesthesia, in amputation of the middle third of the
thigh, was first accomplished by Crile in 1899 (‘Cleveland Medical
Gazette,’ July 1, 1899, vol. xiv), and by Berndt (Gritti's osteoplastic
amputation) (“Muench. Med. Wochenschr.,’ 1899, No. 27), the former
by the intraneural and the latter by the paraneural methods. I
know of no case in which the disarticulation of the hip has been done
by “blocking’ the nerves, though I believe that this is feasible when
it is possible to cut the soft parts at a lower level, as in the Furneaux-
Jordan amputation. In such a case the preliminary anesthesia of the
anterior crural and external cutaneous at the groin, and the sciatic,
just below the gluteus maximus muscle, will suffice, if care is taken
not to cut the obturator, when this is reached in making the deeper
inner section of the thigh, until this nerve has been recognized and
infiltrated. In amputation at a higher level (Wyeth’s operation)
the anesthesia could only be accomplished by a preliminary circular
infiltration, including the individual nerve-trunks, which would
have to be anesthetized as they were met. Such a procedure would
tax the self-control of the patient to the utmost, and would be so
tedious that it could scarcely be recommended except in very thin
and wasted subjects” (Matas)
In amputations at the lower third of the thigh, as well as at the
middle, disarticulations at the knee or amputations at the knee, as
in the Gritti-Stokes operation, the difficulties presented by the ob-
turator nerve are more easily met. The anterior crural, external
cutaneous, great sciatic, and lesser Sciatic should all be injected intra-
neurally at the root of the limb with o.5 of I per cent. novocain solu-
tion, with a few drops of adrenalin solution (I: Iooo) to the ounce.
It is very necessary not to overlook the lesser sciatic, which lies just
to the inner side of the great sciatic, where this nerve enters the
limb, as its branches are distributed to the skin as low down as the
popliteal space and back part of the leg; it is probable that some
failures reported by this method have been due to this neglect as well
as other details. It is more convenient, when operating by the neuro-
regional method, to use a posterior rachet incision, after the posterior
incision has been made, and the deep muscles slightly separated with
the finger to expose the vessels; a long needle is used to infiltrate the
THE UPPER AND LOWER EXTREMITIES 251
region around the vessels (the path of the obturator nerve) with
solution No. 1 or less freely with o.5 per cent. novocain; a few min-
utes following this last injection all parts involved in the field of
operation should be as anesthetic as under general narcosis and the
steps of the operation proceeded within the usual way. It would seem
unnecessary to state that all these operations should be performed with
the use of a constrictor applied to the upper part of the thigh after
the injection of the crural, external cutaneous, and sciatic nerves.
The incisions made to expose these nerves should not be perma-
nently closed until the operation is completed, but only loosely ap-
Fig. 50-Method of securing anesthesia of femur for supracondyloid osteotomy. (Braun.)
proximated with superficial stitches, for if anesthesia is not com-
plete it may be necessary to reopen the wounds for further infiltra-
tion of the nerves; this, however, will not be at all likely if the nerve
has been properly infiltrated, producing a fusiform enlargement at
the point of injection, in the case of a very large nerve like the great
sciatic entering the needle at two or more points in the nerve; this,
as mentioned elsewhere, should be a very fine needle entered in the
long axis of the nerve-fibers; care should also be observed not to make
traction on the nerve, which will cause pain, but to make the injection
when the nerve is slack. Some operators in discussing these opera-
tions have preferred, after injecting the anterior crural and external

252 LOCAL ANESTHESIA
cutaneous nerves at Poupart’s ligament, to infiltrate the superficial
tissues on the back of the thigh, making the handle of the racket in-
cision first, and exposing the Sciatic nerve or its branches at the upper
part of this incision and injecting them high up here, then infiltrating
the recognized course of the obturator nerve. The objection we have
to offer to this procedure is that the Small Sciatic is not injected, and
its territory, together with that of any of the branches of the great
sciatic given off above the point of its injection, will have to be infil-
trated. In the operations about the knee-joint—disarticulations and
Gritti-Stokes amputation—these objections are not of as much conse-
quence, as the area here to be infiltrated is necessarily much smaller.
For operations upon the femur, as in the removal of osteomas,
sequestrotomy, etc., the method of injecting around the bone is
shown graphically in Fig. 5o. If the operation is to be performed
exclusively by infiltration, the soft parts must be infiltrated from
the skin to the periosteum along the proposed line of incision; or super-
ficial regional methods may be employed, in addition to the periosteal
injections, by blocking the external cutaneous or anterior crural
nerves just below Poupart's ligament, and this would seem the pref-
erable plan except in emaciated subjects.
THE KNEE-JOINT
As this joint receives, either in its cutaneous covering or deeper
parts, branches from practically all the nerves in the lower part of
the thigh, what has been said regarding the neuroregional methods
of that part are equally applicable here.
It will be seen that the deeply situated and difficultly accessible
obturator nerve may offer serious obstacles to a thorough and satis-
factory anesthesia of this part; it is here, then, that Bier's venous
anesthesia or spinal puncture may be advantageously used; however,
in the hands of the skilful operator, this disadvantage may be over-
come, and almost any operation on the joint performed by purely
regional methods.
First block the anterior crural, external cutaneous, and sciatic
nerves at the root of the limb; this will leave only the territory sup-
plied by the obturator unanesthetized, which is represented by a small
area on the inner side of the knee and a part of the joint. With all the
other parts anesthetized, the operative incision could be made in such
a way as to expose or easily approach the path of the obturator nerve
on the inner side and just above the knee, and sufficiently deep to feel
freely the femoral vessels; rather free infiltration between and around
THE UPPER AND LOWER EXTREMITIES 253
the vessels and on their inner side should reach all branches of the nerve
and leave the parts below completely anesthetic. Such a thorough
procedure as the above will, however, only be necessary in extensive
resections of the joint, many lesser procedures involving only the
anterior parts of the joint (the parts most frequently the site of surgical
intervention) can be easily performed through infiltration, or by block-
ing the anterior crural and external cutaneous nerves at Poupart's
ligament. The latter procedure will suffice for the operative treat-
ment of fracture of the patella, drainage in infected arthritis, the
removal of foreign bodies, lipomatosis, and other similar conditions.
In operating upon fracture of the patella by infiltration, the joint
cavity should be filled with I or 2 ounces of solution No. 2, with
5 drops of adrenalin (I: Iooo), and allowed to remain for from five
Fig. 51.-Peri-articular infiltration for operation in patella region. (Braun.)
to ten minutes before the joint is opened; this will anesthetize the
synovial surfaces and permit the painless removal of clots or a thor-
ough washing out of the joint. Even strong solutions, up to 2 per cent.
novocain, could be used if necessary, as most of it escapes after the
joint is opened. It is, of course, advisable to use a constrictor above
the knee in extensive operations here under infiltration and after
making a strong intra-articular injection. The method of infiltrating
around the patella region is seen in Fig. 51.
These intra-articular injections may be made use of in breaking
up adhesions within the joint when not too firm; it should be with-
drawn after five or ten minutes and the necessary manipulations re-
sorted to; or, after withdrawing the anesthetic solution, it can be re-
placed with the 2 per cent, formalin-glycerin solution of Murphy,

254 LOCAL ANESTHESIA
which, by its hydroscopic action, moderately distends the joint cav-
ity and thus prevents further immediate contact of the joint surfaces,
particularly when combined with extension.
THE LEG
All operations below the knee, involving the leg, ankle, and foot,
no matter what their extent, can be painlessly performed by a single
method. When near the knee by injecting the external cutaneous,
anterior crural, and sciatic nerves as in the higher operations; if some
distance below the knee (middle third of the leg and below), it will be
sufficient to inject the sciatics at the root of the thigh and the long
saphenous by a paraneural injection, made transversely over the inner
surface of the knee between the tendons of the Sartorius and gracilis
muscles, where this nerve becomes superficial.
It would seem superfluous to detail or describe the many opera-
tions possible, for where a part is thoroughly anesthetic all opera-
tions are possible. -
The following is taken from Prof. Matas' report on “Local and
Regional Anesthesia,” etc., 1900, and cites one of the many clinical
cases which might be mentioned to illustrate these procedures:
“Without any previous knowledge of Crile's work, and encouraged
by previous successes with the same methods, as applied to the upper
extremity, I performed a Pirogoff operation for frost-bite by this
method in March, 1899. From March, 1899, to present date I have
availed myself of this mode of anesthesia many times, my colleagues
operating on other cases in their practice at the Charity Hospital and
elsewhere. In my cases there were reasons which made the adminis-
tration of a general anesthetic undesirable.
“In one of these, operated on before the medical class of Tulane
University, the inestimable advantage of possessing a reliable safe
method of analgesia as an alternative to general narcosis was made
particularly apparent. This case not only illustrates the circum-
stances in which this method is especially applicable, but it will serve
to describe the technic of the method as well.
“F. S. W., aged thirty-two, was admitted to the hospital December 18, 1899, for the
treatment of a diffuse tubercular arthritis of the right tarsus. The patient was suffering
with advanced pulmonary tuberculosis (cavity in lung), but his sufferings were so great
that an operation was decided upon. In view of his weakened condition, special precau-
tions were taken to guard against the accidents of general anesthesia. In addition to
the preparatory administration of strychnin, digitalis, and nitroglycerin by hypodermic,
the nares were sprayed with a 2 per cent. cocain solution to diminish the nasolaryngeal
reflexes (Franck-Rosenberg). Chloroform was then administered over an Esmarch mask
THE UPPER AND LOWER EXTREMITIES 255
by the “guttatim” method. Notwithstanding all the care taken, the patient rapidly entered
into a most violent stage of excitement and became rigid and cyanosed; respiration was
arrested, the pulse became irregular and imperceptible, and when the tetanic rigidity ceased
the patient sank as if completely collapsed, and it was only by the immediate application of
artificial respiration and other measures that he finally came back to consciousness again.
“As the operation was imperative and all general anesthetics were not to be thought
of (ether being contra-indicated by the phthisis), I decided to try the intraneural method
of regional anesthesia, which should have been the method of election at the start. Ac-
cordingly, after careful preparation of the parts, the skin and underlying tissues of the
upper popliteal space were infiltrated with a Schleich No. 1 cocain solution, and an inci-
sion 4 inches long was made so as to bring the sciatic nerve into view. This done, an injec-
tion of 25 minims of the same No. 1 (; of I per cent.) solution was injected into the trunk
of the nerve. A constrictor was applied—after exsanguinating the limb by gravity—care
being taken to pad the limb well so as to minimize the discomfort it might produce. Eigh-
teen minutes after the injection of the cocain some sensibility still existed in the foot; fear-
ing that the solution would be insufficient, 20 minims of a 1 per cent. cocain were then
injected into the exposed nerve. In three minutes the anesthesia of the entire region be-
low the sciatic infiltration was complete and the operation was begun twenty-five minutes
after the first injection into the nerve had been given. The tarsus was then explored by
making a free externolateral incision, and all the bones, including the tarsometatarsal
articulation, were found to be involved in a diffuse tuberculosis. The astragalus alone
was Saved. The chisel, gouge, and bone curet were used freely with the hope that a simple
excision might suffice, but the lesions of the skeleton and soft parts, including the tendon-
sheaths, were so extensive that an atypical subastragaloid amputation on the Roux-
Lignerolles plan was decided upon. The patient, who had been perfectly quiet and passive,
was now asked his consent to the amputation, which at first he refused, but, after showing
him the extent of the lesions and explaining to him the advantages of a radical extirpation
in a man in his condition, he consented, and the amputation was performed.
“The patient gave us very material assistance in this operation, not only by holding
his foot and leg in the most favorable attitudes for our work, but by turning his body around
without assistance when, at the termination of the operation on the foot, we closed per-
manently the sciatic incision. The contrast between the alarming condition induced by
the general anesthetic (chloroform) and the passive and calm attitude of the patient
throughout the operation was most impressive. In this case it should be mentioned the
Saphenous nerve was not injected, as in the other similar cases; but, instead of this, the
short incision through the skin connecting the inner border of the foot with its outer edge,
which is supplied by this nerve, was bridged over by a line of infiltration edema. The
operations successfully performed by this method in my practice have been (1) Pirogoff’s
amputation for frost-bite; (2) Syme’s operation; (3) two atypical resections of the tibio-
astragaloid joint, in which the astragalus and calcaneum were excised together with the
tibiofibular surfaces and their malleoli, for tuberculosis; (4) Guyon's supramalleolar am-
putation of the leg for trauma; and (5) an extensive search in the thigh for a lost bullet
embedded in the neighborhood of Hunter’s canal. In the last case the anterior crural
nerve and external cutaneous were cocainized under Poupart’s ligament. In this case
we were misled in the situation of the bullet as indicated by radiograph, and failed to find
the bullet even after a most extensive dissection in the lateral and posterior femoral aspects
of the thigh had been made. The anesthesia in this case was complete from the middle of
the thigh to the toes, but there was marked sensation in the upper femoral regions in
consequence of the preservation of the lesser sciatic filaments which overlapped beyond the
points of the greater sciatic infiltration which had been effected just below the crossing of
the lower gluteal fibers. The small area of persistent dermal sensibility could have been
easily controlled by a short transverse line of purely dermal infiltration, the deeper parts
being completely insensitive.”
256 LOCAL ANESTHESIA
The Toes Metatarsals, and Sole of the Foot.—What has been
said regarding the fingers and metacarpals may be largely repeated
for the foot. With certain modifications, any of the smaller toes may
be easily anesthetized by edemetization carried around its base.
The big toe is, however, more effectually treated by paraneural in-
jections made around the base, or, as in Fig. 52, when operating for
bunions, by resecting the head of the metatarsal. In operating for
ingrowing toe-nails, Dr. Braun speaks highly of the use of ethyl-
chlorid spray, used about the base of the toe, claiming it is to be
quite sufficient to remove the matrix as well as the nail. We have
never used this method, always preferring to use infiltration or para-
neural injections at the base with solution No. 1, to which is added 5
drops of 1:1ooo adrenalin to the ounce. This method has the ad-
I
!
Fig. 52.-Points of injections and lines of infiltration for bunion operations or resection
of great toe. (From Braun.)
vantage of producing quite a lasting analgesia, and by the time sensa-
tion does return very little pain is experienced; should the operation
be performed in the office and the patient allowed to go home after-
ward, he is quite likely to reach his destination before any discomfort
is felt, although few rarely complain of any but slight soreness follow-
ing. Figure 55 shows method of anesthetizing the lesser toes.
In operations upon the sole of the feet for removal of splinters and
other foreign bodies it is often quite a difficult matter to satisfactorily
infiltrate the pulp of the foot; this tissue is so dense and unyielding that
even with solutions of considerable strength much difficulty is expe-
rienced. Rather than continue at efforts of infiltration after this
has been found difficult, it would be simpler and preferable to at once
make a paraneural injection around the posterior tibial nerve, as

THE UPPER AND LOWER = EXTREMITIES 257
described in the following experiments, thus securing at once anesthe-
sia of the entire foot; additional injections being made over the
inner or outer ankles to reach the branches of the long saphenous or
peroneal nerves should this be necessary. A review of the follow-
ing quotations from Braun (“Die Lokal Anesthesie”), will suggest
many useful applications in practical surgery when limited in extent
or confined to the superficial parts, but any extensive operations
involving resections of the foot had better be performed by the
intraneural methods of blocking the nerve higher up, as already
described.
Extensor hall. ---Tºbiaſis ant.
|^ Tºbialis post.
Aº L-Feror dig.
..”
Eart. saphenous nerve
Fig. 53.-Method of reaching posterior tibial nerve at ankle-joint for paraneural injec-
tion. (From Braun.)
Figure 53, from Braun (“Die Lokal Anesthesie”), shows a cross-
section through the ankle-joint, at the level of the most prominent
portion of the internal malleolus; the posterior tibial nerve is best
reached as indicated by the arrow, the artery lying internal to the
nerve. Braun gives the following directions for reaching it at this
point: “The needle is inserted about 1 cm. from the inner side of tendo
achilles, and directed from behind forward until the posterior surface
of the tibia is reached; the needle is then slightly withdrawn and the
solution injected. He states that the injury of the vessel which lies
on the inner side of the nerve is hardly to be feared, but it should first
be made sure that the point of the needle is not in the vessel, by





17
258 LOCAL ANESTHESIA
resorting to a little aspiration before the injection is made by slightly
withdrawing the plunger. Should it be found that the vessel has been
punctured, no unpleasant consequences are likely to result if the
needle has been fine.”
The following experiment indicates the results of an injection
made in this manner:
“Experiment 1 (Dr. B.). One-half cubic centimeter of a 1 per cent. solution with 1
drop of adrenalin (1 : 10oo) was injected in the above-described manner, and almost im-
mediately anesthesia appeared as indicated in Fig. 54, No. 1, and lasted for three hours.”
The affected area on the extensor surface of the foot and toe is indicated by the shaded
surface.”
- - -
S.
- - - - - - -
Fig. 54.-Lines of subcutaneous infiltration and resulting areas of anesthesia in foot.
(From Braun.)
This procedure was once employed for opening an abscess and
removing a foreign body from the sole of the foot. The anesthesia
extends to the metatarsals and tarsus:
“Experiment 2. Two cubic centimeters of o.5 per cent. cocain solution with 4 drops
adrenalin solution, injected subcutaneously over the inner ankle, beginning behind the
tendo achillis and extending around to the middle line of the joint in front. This will
meet the terminal branches of the internal saphenous nerve; the extent of the resulting
anesthesia is shown in Fig. 54, No. 2.”
The injection in Experiment 2 reaches the terminal branches
of the internal saphenous nerve, and may often be combined with the

THE UPPER AND LOWER EXTREMITIES 259
injection of the posterior tibial, as in Experiment 1, for anesthesia of
the inner side and sole of the foot.
In commenting upon these experiments, Braun states that a
subcutaneous injection, made across the extensor surface of the
ankle-joint, reaches only a few of the fibers of the internal saphenous
and produces only a limited area of anesthesia on the back of the
foot, the same as in a corresponding injection made on the back of the
hand, while a much more extensive area is affected if the injection is
made slightly higher, as in Experiment 3, where the superficial branches
of the peroneal nerves are reached.
Fig. 55–Disarticulation of third toe. (From Braun.)
“Experiment 3. Three cubic centimeters of o.5 per cent. cocain solution with the ad-
dition of Io drops adrenalin solution (1:1ooo) was injected a hand's breadth above the outer
ankle, across the axis of the limb, from the tendo Achillis behind to the edge of the tibia
in front. After six minutes the skin, as indicated in Fig. 54, No. 3, had become anesthetic
and remained so for three to four hours.”
In discussing this experiment, Braun states that this injection
reaches all of the superficial fibers of the peroneal nerve, the anes-
thetic field extending from the territory of distribution of the internal
saphenous at the inner ankle and inner side of the foot across the
dorsum to the outer side of the foot. The results obtained in Ex-
periment 4 may also at times be applied practically.

26o LOCAL ANESTHESIA
-
“Experiment 4. Three fingers'-breadth above the internal ankle the needle was en-
tered laterally, between the tendons of the tibialis anticus and extensor hallucis longus,
vertical to the cutaneous surface till the bone was reached; the needle was now turned
laterally under the tendon of the extensor hallucis and an injection of I c.c. of o.5 per cent.
cocain with 3 drops adrenalin solution (1:10oo) was injected; ten minutes later anes-
thesia was established in the terminal branches of the peroneus profundus, as indicated in
Fig. 54, No. 4.”
Fig. 56—Area of anesthesia for tenotomy of tendo-achilles. (Braun.)
The method of infiltration for tenotomy of the tendo achilles is
shown in Fig. 56, the infiltration carried well down around the tendon.

CHAPTER XV
NECK
“IN the Surgery of this region local anesthesia has made large
and permanent conquests. The neck is most favorable for the dis-
play of the infiltration method, the paraneural and intraneural meth-
Ods of regional anesthesia having found comparatively few typical
applications. In the neck the lesions of the skin and its appendages
and those of the Supra-aponeurotic planes are everywhere submissive
to cocain or its allies. Local infiltration is most valuable in dealing
with inflammatory lesions—abscesses, boils, inflamed sebaceous cysts,
and carbuncles of moderate size. In opening deep cervical abscesses
connected with submaxillary and pharyngotonsillar infections, in
which the Suppurative focus must be reached by careful dissection
(the Hilton-Rose method), it is invaluable.
“In the major surgery of the neck, local infiltration finds its most
brilliant applications in the anterior cervical and subclavian regions,
and in the operations on the vessels in the carotid triangles.
“Apart from the avoidance of postoperative constitutional dis-
turbances, the immediate advantages of local anesthesia are that it
permits the dissection of the parts with the precision, neatness, and
deliberation that are required in all the deep vascular regions; that the
great turgidity of the veins and general increase in vascularity inci-
dent to the use of inhalation anesthetics is avoided; and that the
surgeon is materially assisted in his work by the different attitudes
that the patient can assume to favor the better exposure of the parts.
“In the postcervical triangle the conditions for local anesthesia
are less favorable, except in the supraclavicular space, in which the
subclavian artery and brachial plexus are readily exposed for opera-
tive purposes” (Matas).
Nerves of the Neck.-In the neck the only opportunity for the
application of regional methods of anesthesia, aside from paravertebral
methods, is to the Superficial branches of the cervical plexus as they
emerge around the posterior border of the sternomastoid about the
middle of the neck (Fig. 57). Here the occipitalis minor, auricularis
magnus, superficialis colli, and the descending or Supraclavicular
261
262 LOCAL ANESTHESIA
branches are all fairly accessible, and in their emergence from the
deeper parts are all met within a comparatively limited area. To
posterior facial vein
w
posterior
Platysma x 2. auricular vein
cervical branch of
* -
º sfernorleido-
facial nerve
- mastoideus
/ /
anterior facial vein
anastortosis with cutaneous
tervical nerve -
external jugular vein-
andstonesis with
facial nerve
cutaneous eervical nerve
-
º
-* Areat occipital nerve
arripital vein
-
orripital artery
* lesser occipital nerve
---- great auricular nerve
– arressory nerve (external br.j
ant jugular rein
Sternodeidomastoideus
jugular venous \ -
arch - v.
A \
- muscular brs, of cervical plexus
T external jugular vein
Omohyoideus ſinferior belly,
posterior supraclavicular
nerves
middle supra:
clavicular nerves
Fig. 57.-The superficial nerves and veins of the left side of the neck (second layer
of neck). The platysma has been divided, the upper portion reflected toward the jaw,
and the lower portion removed. The fascia has been divided along the facial veins.
X = Anastomosis of accessory nerve with cervical plexus. -- = Communication of ex-
ternal jugular vein with deep veins. The upper perforating branches of the internal
mammary vessels (not represented in the illustration) make their appearance between
the origins of the sternocleidomastoideus. (Sobotta and McMurrich.)
anterior supraclavicular nerves
reach and block these nerves in this position it is, however, not neces-
sary to make an open dissection, though this can be done, applying























NECK 263
intraneural or perineural injections to each individual nerve; it will,
however, be found equally satisfactory and much simpler to pass a
long needle down to the posterior region of the sternomastoid at the
midpart of its course to the point of emergence of these nerves, and
here making a fairly liberal infiltration of from 3 to 4 drams of
I per cent. novocain, containing a few drops of adrenalin, distributing
the solution up and down this area for about 2% inches, thus effectually
reaching all these nerves. The result of such an injection is seen in
the anesthetic area, as indicated in Fig. 58 (ten or fifteen minutes' delay
is necessary for the full effect to be shown). The anesthesia of the
superficial parts is complete almost to the midline of the neck; here
the nerves from the opposite side lap over; it will consequently be
Fig. 58.-Line of deep subcutaneous infiltration over sternomastoid and resulting area
of anesthesia. (From Braun.)
necessary to make the injection on both sides if the operation is to be
near the midline.
The depth of the anesthesia will depend upon the depth of the
injection; however, in making the injection into the deep parts,
care should be taken not to pass the needle too far forward under
the sternomastoid, for fear of injuring the deep vessels in this
position. -
Some of the deep branches will be found, upon deep dissections,
to have escaped the effect of the injection; these deep branches are
for the anterior parts, communicating branches to the pneumogastric,
hypoglossal, and sympathetic nerves, communicans hypoglossi and
muscular branches; posteriorly, these are communicating branches
to the spinal accessory and a deep muscular set.
However, for extensive dissections of this region, the above-
mentioned method will be found extremely helpful, greatly lessening

264 LOCAL ANESTHESIA
the amount of infiltration which will be needed and this only in the
deeper parts.
Innervation of the Larynx.-This is through the superior and
inferior laryngeal nerves. The superior laryngeal divides, by the
side of the pharynx, into internal and external branches; the internal,
the principal nerve of sensation, passes through the thyrohyoid mem-
brane, just below the posterior extremity of the hyoid bone, and,
after coursing a short distance forward between the membranes,
enters the larynx; this nerve supplies sensation to all parts above the
vocal cords as far as the base of the tongue.
Fig. 59.-Method of making paraneural injection for superior laryngeal nerve.
To reach this nerve for regional infiltration have the patient lie
on his back, with a small pillow under the back of his neck; have an
assistant, by pressure on the opposite side, displace the hyoid bone
from one side, rendering it more prominent; with an index-finger
on the great cornu, the needle is passed down in this direction and 2 or
3 c.c. of o.5 per cent. novocain with I drop of adrenalin (I: Tooo) is
injected into the thyrohyoid membrane, a little below and in front
(about ; inch) of the great cornu (Fig. 59); the opposite side is treated
the same way; the anesthesia appears in from five to ten minutes,
and frequently lasts one hour or longer, and is sufficient for all opera-
tions above the vocal cords. The external laryngeal passes down the

NECK 265
side of the larynx beneath the sternothyroid and is distributed to the
Cricothyroid muscle; it also contains sensory filaments. The inferior
or recurrent laryngeal passes up in the grove between the trachea
and esophagus, and passes under the lower border of the inferior
Constrictor; entering the larynx behind the articulation of the inferior
Cornu of the thyroid cartilage with the cricoid, it is distributed to all
muscles except the Cricothyroid, and supplies sensation to all parts
below the vocal cords.
Before the introduction of cocain and its successful application
to this region investigators attempted to produce anesthesia of the
larynx in many ways. Eulenburg injected solutions of morphin into
the thyrohyoid membrane at the point of entrance of the internal
laryngeal nerve, and obtained in this way a certain amount of anes-
thesia of the larynx. Later other substances, such as saponin, were
used in a similar way by Pelikan, Köhler, and others. Rossbach has
produced an anesthesia of the larynx by freezing the tissues over the
point of entrance of the above nerve for two or three minutes by the
use of ether spray. Since the advent of cocain and its congeners, these
earlier efforts, while in the right direction, are only of interest his–
torically.
OPERATIONS ON THE NECK
Ligation of the Common Carotid Artery.—This is easily access-
ible in any part of its course. Infiltration with a few drams of solu-
tion No. 1, used first in the skin and subcutaneous tissues and suc-
cessively in the deeper layers as they are approached (Fig. 60), render
this procedure extremely easy; with very few exceptions this vessel
should never be ligated except under local anesthesia, and, instead of
the ordinary ligature, it is far safer to use aluminum bands, as recom-
mended by Matas and Allen. It has been recognized that it is never
safe, even in young subjects (here we may have deficiencies in the
circle of Willis), to cut off the blood-supply from Such vessels as the
common or internal carotid without first being Sure of the Com-
petency of the collateral circulation; for this reason ligation or oc-
clusion should, if possible, always be done under local anesthesia, So
that the sensations of the patient may at once be determined, which
would not be the case with a general anesthetic, and, instead of using
a ligature which produces permanent damage to the artery, the
aluminum bands, as recommended by the author, should be substi-
tuted, which are capable of removal without damage to the vessel,
if necessary, as long after as seventy-two hours.
266 LOCAL ANESTHESIA
It is accordingly always our practice to occlude these vessels in
the above manner and always under local anesthesia."
The internal and external carotids, except in very stout subjects
and in case of abnormally high division, are easily exposed at their
origins through infiltration with local anesthesia and need no special
description (Fig. 60).
The internal jugular vein, except at the base of the skull, is easily
accessible throughout its entire course, and may require ligation or
excision, as in the case of septic thrombosis from middle-ear disease.
Fig. 60–1, Area of anesthesia for exposing external carotid artery; 2, common carotid.
In operating under conditions of this kind, where it is often uncertain
to what extent the vessel will have to be exposed, it is preferable to
block the cervical plexus as already described, thus securing anes-
thesia of the superficial parts throughout the entire extent of the vein;
it would then be necessary to use only light infiltration anesthesia
as the deeper parts are approached.
The subclavian artery is easily exposed by infiltration in its
1 Occlusion of large surgical arteries with removable metallic bands to test the efficiency
of the collateral circulation (Matas and Allen, “Jour. Amer. Med. Assoc.,” January 28,
1911).

NECK 267
Second and third portions, but has been ligated without much diffi-
culty and painlessly by Matas in the first portion as well.
Lymphatic Glands.-Isolated groups of diseased glands when
well defined can be easily removed by infiltration of the surrounding
parts, but when extensive, as is often the case in tubercular adenitis,
had best be left to the domain of general anesthesia.
The Submaxillary and submental groups are quite accessible to
extirpation by local infiltration and no special technic is required.
Malignant disease unless superficial or well defined, had better
be operated by general anesthesia unless contra-indicated; when
Operating by local methods, as already advised, care must be taken
not to infiltrate diseased tissues, but to create a zone of anesthesia
around the area to be extirpated by the Hackenbuch plan; non-
malignant growths when well defined are easily removed (Fig. 19).
The following case, reported by Dr. Matas in 1900, illustrates the
possibilities here:
“One of the most extensive operations performed with cocain anesthesia was the ex-
tirpation of a large retropharyngeal fibroma of more than thirty years’ duration in a very
aged negro, who sought relief in our hospital service four years ago. In this case the
removal of the growth became imperative, on account of progressive inanition and maras-
mus induced by the outward displacement of the pharynx and esophagus. The larynx
and trachea were also so displaced by the neoplasm that breathing was seriously ob-
structed. The huge mass occupied the right half of the neck and bulged under and to the
outer side of the sternomastoid, which was spread like a thin sheet in front and to the inner
side of it. The right carotid was displaced to the left of the median line and could be felt
pulsating under the skin. The skin was cocainized in a line extending from the mastoid
to the sternoclavicular joint in the long axis of the tumor. The tumor immediately
bulged out the moment the tension of the overlying aponeurosis was relieved. The divi-
sion of the sternomastoid materially aided in prolapsing the tumor, which was easily
enucleated by peeling it away from the surrounding tissues. It was then lifted out of the
wound, and a broad pedicle attached to the posterior pharyngeal wall, tonsil, and basilar
of the occipital was divided, after securing a number of nutrient vessels, while an assistant
controlled the exposed carotid, at a lower point, by digital pressure.
“In removing the growth from its tonsillar and pharyngeal attachments the pharynx
was opened and part of its lateral wall was excised. The fauces, root of the tongue, and
glottis were exposed. The opening was closed with silk, and after the extirpation of the
parts the dislocated larynx and other organs were replaced in their natural position. The
mass was a fibroma and weighed 4% pounds. The manner in which the old man withstood
this huge traumatism was remarkable. He never moved or uttered a word of complaint,
and his slow pulse never wavered until traction was made upon the pharyngeal pedicle.
In this case it must be recognized that we were dealing with a stoic of Spartan type,
and that as much credit is due to his heroism as to the cocain, which was only used to
anesthetize the skin and pharyngeal attachment of the tumor.
“It is a source of genuine Sorrow and regret that so brave a man should not have been
awarded by a better result than that which followed this extraordinary exhibition of
psychic fortitude. After lightly packing the vast cavity left in the neck with a weak
iodoform gauze and reducing the length of the cutaneous incision by a few stitches, the
268 LOCAL ANESTHESIA
patient was sent to bed and thoroughly stimulated. His pulse was slow and full, and he
expressed himself as being very comfortable. He was well until about seven hours after
the operation, when suddenly and without any warning he sank into a syncopal spell
and died in a few minutes, before any assistance could be rendered. The exact cause of
death was never ascertained, but it is presumed that death was caused by thrombus or
embolus.”
THE LARYNX AND TRACHEA
The great advantage of operating without inhalation narcosis in the
asphyxiating diseases of the larynx and trachea, requiring laryngotomy
and tracheotomy, led to the early trial of cocain in these operations.
In small children, suffering from diphtheria, the restlessness
and pscychic disturbance of the patient contra-indicates its use;
here, however, incubation has practically supplanted tracheotomy
altogether.
But in operations on the laryngotracheal passages in adults local
anesthesia has become the routine procedure, and its success in these
cases is as fully and indisputably established as it is in the removal
of an ingrowing toe-nail. º
Dr. Matas first performed tracheotomy under cocain in 1889 in
relieving a laryngeal stenosis from abductor paralysis, and since
that time it has become the routine anesthetic in our practice. We
have had occasion to test its value in such delicate intralaryngeal opera-
tions as the extirpation of the vocal bands for paralytic stenosis, using
a Trendelenburg tampon-cannula to prevent the entrance of blood into
the lower trachea and in the removal of foreign bodies. In these
operations the reflex irritability of the mucosa must also be subdued
by spraying the larynx directly with cocain solution. Such formid-
able major operations as laryngectomy may prove more difficult to
any but the experienced operator under local anesthesia; however,
it is thoroughly feasible, though tedious; but, in view of the tremen-
dous mortality associated with this operation under inhalation nar-
cosis, due to pneumonia, it has much to recommend it, and we believe
should never be done under general anesthesia.
This procedure is best illustrated by a report of the following case
by the author.
Laryngectomy.—The advantage of the routine use of local anes-
thesia in all minor operations upon the upper respiratory passages.
which do not require great haste, such as tracheotomy, laryngotomy,
etc., is readily conceded by most Surgeons; many of whom, however,
would hesitate to employ it for such major operations as laryngec-
tomy.
This formidable procedure, attended by high mortality (about
NECK 269
25 per cent in cases collected from all sources), due largely to pneu-
monia, no doubt partly contributed to by the irritating effects of
the anesthetic, can be performed under purely local and regional
methods of anesthesia with no greater difficulties to the experienced
than those attendant upon herniotomy under local anesthesia, and
should certainly present a mortality far below the discouraging statis-
tics presented under general anesthesia.
The following case illustrates the technic employed in a bad case
involving the larynx and esophagus:
Fig. 61.-Area of anesthesia for laryngectomy. Over double-lined area on sides infiltration
is more liberal and is carried well down to sternomastoid muscle.
May 30, 1912: Preliminary tracheotomy under local anesthesia to relieve the dysp-
neal.
June 3, 1912: Gastrostomy by the Ssabanajew-Frank method under local anesthesia
to secure safe and easy access to the stomach and enable us to have full control over nutri-
tion following operation.
The Operation, June Io, 1912, 1o A. M.: Preliminary preparatory hypodermic of
morphin, grain; scopolamin, rim grain, to prevent any pscyhic disturbance or uneasi-
ness on the part of the patient.
The anesthetic solution used is the one in use in our clinic for general surgical pur-
poses: novocain, o.25 percent., NaCl, o.4 per cent., plus 10 to 15 drops of adrenalin (1:10oo)
to each 4 ounces of the solution to be used.
A deep subcutaneous injection of about 1 + ounces of the above solution was made on
each side of the neck, over the middle of the sternomastoid, distributed up and down the
course of the muscles for about 2 inches; this blocks the superficial branches of the cervical
nerves (Fig. 61).

27O LOCAL ANESTHESIA
The hyoid bone was then displaced to one side to render it more prominent, and the
needle inserted just beneath the cornu and about 2 drams injected on each side in this
manner into the substance of the thyrohyoid membrane; from this point forward on each
side another 2 drams was distributed subcutaneously over the surface of the hyoid bone;
this blocks the superior laryngeal and descending branches of the hypoglossal.
Following this last injection the skin of the midline of the neck was tested and found
anesthetic. An incision was then made from the hyoid bone to near the sternum in the
midline, and a short cross-incision joined this at right angles, above near the hyoid and
below near the sternum; at this last point a little Šubcutaneous infiltration was previously
done for fear that the anesthesia would not extend out the full distance of the proposed
incision. -
These incisions were extended down to beneath the platysma, which was dissected
up and turned out with the skin flaps, exposing the deeper plane of muscles; the sterno-
mastoid on each side was now partially divided to allow freer access. The sternohyoid
and sternothyroid muscles were divided below and retracted upward, exposing the thyroid
gland; this was divided at the isthmus, ligated, and pushed to either side.
The trachea was now freely exposed, and the interval between it and the esophagus
gently infiltrated low down on each side to block the recurrent laryngeal nerve. With
a finger passed in as a guide alongside of the larynx, the cellular tissue was lightly infil-
trated as far back as the vertebral column and extending well up toward the pharynx;
this was the last injection made, and reached the deeper fibers of the cervical and pharyn-
geal plexuses, which were not anesthetized by our more superficial injections. The sub-
sequent steps of the operation were division of the trachea and its suture to the skin over
the episternal notch. Division of the larynx in the middle line to learn the exact extent
of the growth and involvement of the esophagus; this was found extensively involved on
its anterior and left lateral surfaces.
The thyrohyoid membrane and esophagus at this level were divided; the esophagus
was stripped up from the vertebral column and divided well below the growth; this re-
moved the esophagus, larynx, and its attached muscles in block. The end of the esophagus
was sutured to the skin in a separate opening some little distance away from the trachea;
this was done as a precautionary measure, instead of closing it now, in the event that the
gastrostomy opening should not prove satisfactory. The pharynx above was next closed,
the skin flaps brought together, and the interval beneath lightly packed with iodoform
gauze.
The operation represented a removal in block of all parts except
the thyroid gland, from just above the sternum to the base of the
tongue, and was entirely without pain. It had previously been ar-
ranged with the patient, who was holding an assistant's hand, that
he was to squeeze it if he felt pain; this he did once very slightly, when
working high up near the pharynx, but when asked if he felt pain he
shook his head; however, slightly more solution was injected into the
pharyngeal wall at this point.
There was no cough or other unpleasant reflexes throughout the
operation; this had been prevented by the early injection of the supe-
rior and recurrent laryngeal nerves, and aspiration of blood or mucus
was prevented by the early division of the trachea and its suture to
the skin in the lower end of the incision out of the immediate field of
operation; very little blood was lost, as all vessels were ligated before
NECK 27I
being divided, and the patient left the table in about the same condi-
tion as when the operation commenced.
The procedure was remarkably free from any unpleasant or an-
noying incidents, and progressed Smoothly from start to finish, and
impressed the writer, as well as others who witnessed it, with the
feasibility and advantages of performing this operation under local
anesthesia.
Tracheotomy, high or low, is easily performed by infiltration
anesthesia in the midline of the neck, and needs no special description.
It is unnecessary to infiltrate the trachea before opening it, as the
mucous membrane is insensitive to pain, but will excite coughing as
soon as instruments or the tracheal tube is placed within it; if for any
reason this is to be avoided at the time, the opening may be retracted
and a spray of Cocain or novocain Solution gently applied to the inte-
rior before the tube is inserted.
Alcohol Injections of the Internal Laryngeal Nerve in Tubercular Lar-
yngitis.-By this method, first recommended by Hoffman, Roth has
treated 33 cases and Levy 3 others. In Roth’s series all had severe
pain on Swallowing, which had resisted all other methods of treat-
ment. In these cases a painful pathognomonic spot is found between
the hyoid bone and the thyroid cartilage corresponding to the point
of entrance of the nerve.
. After disinfection with alcohol (not ether, which causes Gough-
ing) an assistant makes pressure upon the opposite side. The painful
point is then located with the finger, and with a somewhat blunt
needle, though an ordinary hypodermic will do, the tissues are pene-
trated to a depth of about 1% cm.; the needle is then directed upward
and outward (Fig. 59); when the nerve is reached the patient Com-
plains of pain radiating toward the ear. Then I to 2 c.c. of 85 per
cent. alcohol, warmed slightly above body heat (45° C.) is slowly
injected; some immediate discomfort is produced which soon sub-
sides, and the resulting analgesia lasts from one to twenty-One days,
one week being the average.
There is no loss of cough reflex or aspiration of food following.
There seems no objection in repeating the injection as often as seems
necessary, the patients often requesting that this be done; there seems
no diminution of the effect in the repeated injections. Both sides may
be injected as well as one, but when one injection is made it is always
over the nerve which seems the tenderest on pressure.
272 LOCAL ANESTHESLA
GOITER
“One of the most convincing proofs of the great extension of local
anesthesia in the surgery of the neck has been given by Kocher and
his followers in their numerous operations for the cure of goiter.
When we consider that the statistics of operations for goiter, as fur-
nished by the clinics of Kocher, Roux, the Reverdins, Socin, Bruns,
Mikulicz, Burkhardt, and other surgeons who practice in the great
zone of goiter infection in Europe, amount to thousands of cases, and
that since the value of cocain as an anesthetic was first established
Fig. 62–Points of injection and area of anesthesia for thyroidectomy. (From Braun.)
by Kocher (who alone claims a large majority of many thousand goiter
cases as cocain operations) local anesthesia has become a routine prac-
tice in such cases, we will realize what a large slice of surgical terri-
tory has been wrested from the domain of general anesthesia in this
region alone” (Matas).
Simple colloid goiter, unless excessively large, is comparatively
easily removed by local anesthesia. Here we do not have the great
nervous tension, with the psychic effect of fear, to contend with as seen
in the exophthalmic type. These goiters may involve one or both
lobes of the gland. The principal nerve-supply is from the cervical

NECK 273
plexus, the nerves running forward from the posterior edge of the
sternomastoid. Consequently, most of our anesthetic solution is
distributed at this point, also creating a light zone of anesthesia around
the gland (Figs. 62 and 63).
First produce a “station” in the skin on the outer side of the
gland, then the long needle can be passed down to the posterior
border of the sternomastoid and an area of infiltration created at this
point, care being taken not to penetrate too deeply for fear of injury
to the carotid and jugular, which lie just in front; from this point the
-
-
Fig. 63–Points of injection and area of anesthesia for thyroidectomy. (From Braun.)
needle should be directed around, first above and then below, the
margin of the tumor, injecting as you go. In case only one lobe is
involved a station is now produced in the skin of the midline over
the trachea, and a free injection made in this position from the skin
down to the trachea as the nerves of the opposite side lap over the
midline.
In the event of both lobes being involved this last injection can
be very light and made principally in the deeper structures. An
injection is then made on the outer side of the opposite lobe over the
posterior border of the sternomastoid similar to the first side.

18
274 LOCAL ANESTHESIA
If the tumor is very large, stations may have to be established above
and below to properly reach the entire circumference of the growth.
The skin incision is usually made across the most prominent part
of the gland, either transverse or curved, according to the shape of the
growth, and the muscles in the midline retracted. When working with
local anesthesia it is better to attack the isthmus of the gland first;
the capsule is peeled back and the isthmus divided, preferably, be-
tween clamps; a syringeful of solution may have to be injected thor-
oughly under the isthmus over the trachea before this can be done.
After the isthmus is divided the gland is rolled out; this early division
of the isthmus and its separation from the trachea relieves the trac-
tion upon this structure in manipulation elsewhere, which might
otherwise cause the patient to complain. As the gland is rolled out
the posterior capsule and underlying tissues will need infiltration,
particularly at the upper pole.
The capsule is pushed back from the gland as it is delivered; the
superior pole is caught between clamps and divided and later ligated,
thus leaving a portion of the gland at this point with the capsule,
which is left behind, containing the parathyroid bodies. The rest of
the operation is simple. The opposite side, if involved, is removed the
same way; if not, the isthmus is ligated.
In closing the wound the muscles in the midline should be replaced
in nearly their same position and the platysma sutured separately,
being careful not to include the platysma or any of the deeper muscles
in the skin suture, as they will be bound together this way in the
resulting cicatrix, which will later pull the skin up and down in an
unpleasant way whenever these muscles act.
In making the first incision the skin and platysma can be divided
at different levels, which further obviates the above result.
A small rubber drain is left in the wound.
Exophthalmic Goiter.—In this type of goiter we are concerned
more especially with the condition the result of the hyperthyroidism
than with the local condition itself. -
The extremely nervous and psychic state of the patient often
associated with grave cardiac changes makes the condition one of
extreme danger when operating by any method of anesthesia. We
believe, however, that many of these cases are better operated by
local methods of anesthesia than by general inhalation narcosis, using
in these cases a slightly larger preliminary dose of morphin and
Scopolamin, giving # gr. of the former and Tło gr. of the latter one
hour beforehand. * *
NECK 275
This very effectually relieves the fear and dread so terrifying in
these patients, and produces a state of apathy in which, if the opera-
tion is carefully and gently performed with a thorough observance
of the anesthetic technic and no pain inflicted, the patient is enabled
to leave the table in much better condition than after a general anes-
thetic.
The best method of dealing with these patients has been the sub-
ject of much thought and investigation on the part of many operators,
and has resulted in a voluminous literature. Dr. Crile at one time
advocated local methods of anesthesia exclusively, but now uses a com-
bined method, not letting the patient know when operation is to be
performed. Various aromatic substances are administered daily on an
inhalation cone as a presumable part of the treatment, which is done
in the patient's room; on the day of the operation anesthetics are
gradually substituted without the patient’s knowledge until narcosis
is produced; the patient is then removed to the operating room. It
is not necessary that this anesthesia be very profound, as the field
is injected freely with local anesthetic solutions which prevent
the transmission of painful impressions. The general anesthesia is
used only to control the psychic state of the patient; it is, conse-
quently, only necessary to produce a subconscious state. (See chapter
on Combined Methods of Anesthesia for a further consideration of
this method.)
The technic of the operation is the same as that given for colloid
goiter.
We have not had occasion to resort to the combined method of
anesthesia in these cases very often, as we have found local anes-
thesia alone was usually very satisfactory, but there is, of course, no
objection to allowing a few whiffs of ether or chloroform or even alco-
hol on a cone should it appear advisable.
We do not mean to convey the impression that all these cases
are operated on by us under local anesthesia, but the majority of them
are. We could relate numerous clinical illustrations, but the following
brief review of a rather severe case, operated on by the author, will
suffice.
Exophthalmic goiter. Trahan, aged twenty-six. Entered Ward 9 July 26, 1908.
Trouble of two years’ duration. Markedly emaciated and weak; prominent, staring
eyes, with a pulsating tumor as large as the fist in the thyroid region. Heart enormously
dilated, weak, rapid, and irregular, with murmurs over the entire chest. Respiration
rapid and irregular, pulse very irregular and weak, varied from 98 to 140. Temperature
from 90° to IoI* F. The right lobe and isthmus were removed; the left lobe, being but
slightly affected, was not disturbed. Anesthesia was perfect (technic same as for colloid
276 * LOCAL ANESTHESIA
goiter). The patient conversed with us during the procedure, and rendered assistance
by turning his head in different positions. He winced once or twice when we pulled on the
trachea in lifting the gland from its bed. He left the table in good condition, apparently
not affected by the operation. His progress for a few days was much disturbed by a weak
and rapid heart, but he finally made a good recovery and left the hospital August 20th.
He wrote me a letter later that he was entirely well.
These cases are particularly suited to local anesthesia, and I doubt
if this particular one could have stood the operation with a general
anesthetic.
It is hardly the purpose of a book of this kind to enter into a dis-
cussion of the many conditions arising in those patients which have
to be considered in selecting the time for operation, also the pre-
paratory and postoperative treatment, all of which are found in the
general surgeries, and do not, as a rule, differ in any respect, whether
the operation is done under general or local anesthesia.
There is, however, a procedure which I would like to speak of here,
either as a palliative operation or as one preparatory to a radical pro-
cedure; namely, ligation of the thyroid vessels. This operation, while
done before, owes much of its popularity to the Mayos. Following the
ligation of the vessels a colloid degeneration takes place in the gland
with subsidence of the symptoms of hyperthyroidism.
After two or three months’ delay the radical removal of the parts
of the glands affected can be undertaken with no greater difficulties
than those attending ordinary goiter. As a preliminary step in the
handling of all severe cases this should be borne in mind, as the pro-
cedure is very easily carried out and involves practically no risk
under local anesthesia, offers quite a boon to these patients, and
should prove a decided factor in reducing the mortality rate in these
Ca,SéS.
The following is from an article by Dr. Chas. H. Mayo, which
appeared in the “Annals of Surgery,” December, 1909: -
“The earliest ligation of vessels as an operation for the relief
of goiter is credited to Wölfler. Our experience with this procedure
covers over 200 operations, and, with the results obtained by this
method, we consider that the ligation of certain thyroid arteries and
veins, and at times a portion of the gland, seems indicated in some
cases of hyperthyroidism. -
“First. In those suffering from mild symptoms of hyperthyroid-
ism, and those in whom the diagnosis is made early, possibly before
the less important eye symptoms or even goiter is present. In cases
which are hardly severe enough to warrant a thyroidectomy the
NECK 277
ligation of the vessels will often produce a cure in a few weeks with
but little risk and without the necessity of special medication.
“Second. Ligation is indicated in that larger group of acute,
Severe exophthalmic goiters, and very sick patients, who, having
exhausted all forms of treatment, are now suffering with various sec-
ondary symptoms—dilatation and degeneration of the heart, fatty
liver, Soft spleen, diseased kidneys, which have resulted from the
chronic toxins, as seen in the later stages of Graves' disease—changes
which, after all, are the final cause of death. This operation is of par-
ticular value in those cases with a marked pulsation and peculiar thrill
of the Superior thyroid arteries.
“All severe cases of hyperthyroidism when suffering from edema,
ascites, dilatation of the heart, diarrhea, or gastric crisis of vomiting
should be under observation for a short time at least, and some of
them for a considerable period of time, to improve their condition,
if possible, before even a ligation be attempted. There is a time
in the progress of these cases when terminal degeneration of essential
organs has advanced so far that they are no longer curable. When
surgery is applied as a last resort it may be possible, by using some
special great dexterity and care, to remove part of the gland without
an immediate fatal result. While the disease may be checked, these
patients are seldom sufficiently benefited to warrant the immoderate
risk of an extirpation. On the other hand, at such times many cases,
which have at first appeared to be unfavorable subjects, will so far
improve under symptomatic treatment, aided by rest, hygiene, x-rays,
etc., as to become suitable operative subjects at a later period. It is
in this class of cases that ligation as a preliminary procedure is of
great value. The relative safety of ligation, as compared with that
of thyroidectomy, may lead the operator to accept as Surgical risks
patients so far advanced in the disease as to have but little prospect of
cure. In operating upon these cases the Surgeon should use his judg-
ment as to the time and method of operation and the anesthesia to be
used from observations, according to the improvement manifest under
preparatory treatment.
“Operation.—A transverse incision gives the best working space
as well as the least disfiguring scar. It is made 2% inches in length,
crossing the central part of the thyroid cartilage. The incision should
be made in a natural skin crease if possible, and should include the
platysma myoides, this one incision being better than two lateral.
The inner border of the sternomastoid is tracted laterally. This
exposes the omohyoid muscle, which is tracted up and in toward the
278 LOCAL ANESTHESIA
midline. Beneath this muscle is the upper pole of the gland with the
superior thyroid artery and vein (Fig. 64).
“The ligating material is linen, passed by an aneurysm needle.
Should a vein be pierced and a hemorrhage follow the placing of the
- - -
-
-
Fig. 64.—Ligation of the superior thyroid vessels. (C. H. Mayo.)
ligature, it is tracted upon, and a second loop is passed around includ-
ing more tissue. In most cases this is preferable to a more generous
incision with freer dissection. The veins are purposely included to
secure venous obstruction, the free anastomosis within the gland




NECK 279
capsule making this of advantage. One need not fear the ligation of
a nerve in this location, as the inferior or recurrent laryngeal is below.
The wound is closed by a subcuticular suture without drainage.
“The location of the ligation at the pole of the gland is important,
as in one of our cases in which the Superior thyroid arteries had been
previously ligated at a point where they were given off from their
origin at the external carotid there was but partial and temporary re-
lief. At the second operation we found a reversal of the circulation
in the large inner branch anastomosing with the inferior thyroid,
and in the upper part of the gland the circulation was but little re-
duced.
“In the large hard glands of hyperthyroidism, where some rever-
sion has occurred with colloid deposit, ligation is not indicated.
The changes in the gland after ligation are most interesting. There is
a change from the great increase in cell development back to the con-
dition of simple goiter. This is produced by a simple exfoliation of
cells, and does not resemble the degenerative changes which are
found in the glands removed in the late stages of Basedow’s disease
or those in which serum treatment has been used. In both of these
there is a true cytolysis or chemical destruction of the cell.
“While many patients reported indefinite gain in weight, there
were 68 cases in which an accurate report was given, showing that
62 patients gained an average of 20% pounds from three to five months
after operation. If cases were excluded that were about normal
weight at the time of operation the average gain would exceed this.
Six patients lost an average of 6 pounds. Most of these were but little
reduced at the time of the operation.
“In the majority of cases the ligation is made as a definite step
in a graduated operation to reduce excessive secretion of the gland,
and some of the reported cases are yet to be operated upon for the
removal of part of the gland as a secondary procedure. Some of the
patients in this series consider themselves too well at present to under-
go another operation, and will probably do so only under the stress of
a relapse of their symptoms, when it may be advisable to ligate the
right inferior thyroid artery as a second step toward thyroidectomy.
We found this procedure of value in 9 cases. On several occasions,
because of the various seemingly urgent reasons involving the Safety
of the patient, we deemed it advisable to convert a thyroidectomy
into a ligation of vessels.” -
For the ligation of the superior thyroid arteries the area of the
superficial anesthesia is shown in Fig. 65. After the skin has been
28o LOCAL ANESTHESIA
passed, deeper injections are made into the parts before their dissec-
tion, making these injections rather liberally around the superior
poles, which must be well blocked before being ligated.
In the preceding pages I have endeavored to point out some of the
uses of local anesthesia in the major surgery of the neck. It is only
fair now to state that there still remains conditions in which it is an
impracticable and unsatisfactory mode of anesthesia. This is par-
ticularly true of all atypical operations in which the lesions and the
limits of the field of operation are ill-defined, as in multiple lymphatic
Fig. 65-Line of infiltration anesthesia for double ligation of superior laryngeal artery.
On each side the injection is made freely into the deep tissues.
tuberculosis, where the chains of infected glands are held fast to the
periglandular tissues by dense adhesions.
In the removal of chains of malignant lymph-nodes the same
objections hold with still greater force, and a general anesthetic
becomes necessary. Malignant tumors, unless well defined, should
rarely if ever be operated upon by infiltration in any region, and when
done the Hackenbuch plan should be followed. These remarks do
not refer to the application of regional methods for this purpose, which
can always be employed.

CHAPTER XVI
THE THORAX AND BACK
IN the major Surgery of this region the local infiltration and
neuroregional methods have yielded excellent results. Except in
children and very nervous patients, many of the commonly per-
formed operations can be as easily and often more safely performed
by these methods than with general anesthesia. This is especially
the case with empyema and hepatic abscess, where the patient is
often exhausted by profound sepsis as well as the antecedent dis-
eases (pneumonia, tuberculosis, or dysentery), and from dyspnea
due to the encroachment upon the pulmonary area by these accu-
mulations. In bad cases of this kind the administration of an anes-
thetic may be extremely hazardous or even absolutely contra-indi-
cated. Here local anesthesia has proved of great value and should
always be given the preference. The infiltration and operation must,
however, be gently and delicately executed. Any undue traction or
pressure on the surrounding sensitive parts will give pain and cause
the patient to complain and lose confidence in the promise of a pain-
less procedure.
The nerves of the thorax are principally the intercostals (anterior
divisions of the dorsal nerves). The upper six, with the exception of
the first and intercostohumeral branch of the second, supply the chest
wall alone; the lower six, after being distributed to the parietes of the
chest for the anterior half of their course, are distributed to the
abdominal wall, the last one (twelfth dorsal) sending a filament as
low down as the hip. In the intercostal spaces these nerves lie just
below the arteries, near the lower border of the ribs, about the middle
of their course, near the anterior axillary line; each gives off a lateral
cutaneous branch, which pierces the muscles to the subcutaneous
tissues and divides into anterior and posterior branches, the anterior
branch running forward as far as the sternum, the posterior coursing
backward in the skin of this region (Fig. 66). In the intercostal
spaces the nerves lie first between the pleura and internal intercostal
muscle, then between the two intercostals to near the middle of the
ribs, when they continue their course between the fibers of the in-
281
282 LOCAL ANESTHESIA
ternal intercostal muscle. In the midline the nerves of each side
overlap for some little distance. In the upper and lateroposterior
innominate
artery
deep cervical artery
right vagus nerve -
costo-cervical trunk-ºs, A --
1 º A_-left subclavian artery
subclavian - - - - ...internal mammary artery X
arteryx
left recurrent nerve
traches % … lºſt vagus nerve
Zºhrenic ner” X
*_bronchial arteries
- A recurrent nerve
|-- | -
supreme intercostal artery (A - - * pulmonary branches
- - of left vagus nerve
right recurrent nerve 1. - - º !ſ left wag
"...º. -
ascending aorta x-A.º. - -
- - - ºleft bronchus x
& - - - oesophageal art.
azygos vein x- - __ - - -- "… º, oesophageal chords
Hof left vagus nerve x
- -- - - -- - - º - ... oesophagus
right bronchus X- º - º - __**
aortir
interrostal
* arteries
interrostal
veins descending
…thoracic aorta
Interrostales
interni
-
thdratic
durº
-
ganglion of -ºſ.
sympathetic or
greatspianºnicº_
nerve -
interrostal º/,
-----> Tº º
sº
º
º
- -
lesser splanthnic- º
ne-
-
azygos rein.
diaphragm 23-
interrostal I.
Wessels XII interrostal nerve.xml bdominal
- -
lesser splanthmir nerve great splinch- :
- nic nerve ascending lumbar vein
- - coeliac arteryx
* mesentericarf. X
Fig. 66,-The large vascular and nervous trunks of the posterior thoracic wall as
viewed from in front and somewhat from the right. *=Location of twelfth rib.
** = Communication between azygos and hemi-azygos veins. (Sobotta and McMurrich.)
regions of the thorax the branches of the brachial plexus and supra-
clavicular nerves are distributed to these parts. -










































THE THORAX AND BACK 283
In front the supraclavicular nerves send branches to the skin of
the thorax nearly as far as the nipple; the external or supra-acromial
branches supply the skin on the upper and back part of the shoulder;
these branches pass obliquely across the outer surface of the trapezius
and the acromion.
In addition to the above, branches of the anterior thoracic nerves
supply the entire area covered by the pectoral muscles, though on a
deeper plane; they send branches through to the surface.
Fig. 67.-Areas of distribution of supraclavicular nerves overlapping field of anterior
thoracic nerves. Area of postthoracic seen laterally: 1, Line of anesthesia for exposing
brachial plexus; 2, line of anesthesia over clavicle for blocking supraclavicular nerves;
long needle is entered over middle of the clavicle and directed subcutaneously toward
each end of the bone; 3, deep infiltration of pectoral muscles from point near middle of
clavicle to axillary margin.
On the side of the chest the posterior or long thoracic extends
downward to the lowest digitations of the surratus magnus.
The typical course of an intercostal nerve is seen in Fig. 132, and in
Fig. 67 is seen the area in which the supraclavicular anterior and
posterior thoracic nerves intermingle in their distribution with branches
from the intercostal.

284 LOCAL ANESTHESIA
In the scapula region behind the thoracic wall is overhung by this
bone and its attached muscles, which will have to be dealt with in
any procedure which involves the chest wall at this point; however,
this is not often the site of surgical intervention.
It will be seen from the above and a study of Fig. 67, which repre-
sents diagramatically the intermingling of the areas of distribution
of these nerves, that any methods of regional anesthesia, when ap-
plied to the anterior chest wall above or the lateral chest wall behind,
must deal with nerves which enter the field from a variety of direc-
tions.
To block the intercostal nerves over a wide area of distribution is
best done behind near the angle of the ribs, where they approach close
-
Fig. 68.-Shows line of anesthesia and points for entering long needle for blocking inter-
costal nerves at angle of ribs.
to the posterior wall and before the lateral branches are given off,
though this can be done at any point of their course.
A vertical line of cutaneous anesthesia is carried down the back
over the angle of the ribs, as seen in Fig. 68; the scapula is carried well
forward and the finger locates the rib; a long fine needle is now passed
down to the interval between the ribs; this is best done obliquely
from below; with a finger pressed firmly on the rib, the needle is made
to pass upward and inward, injecting as it is advanced until it strikes
the bone; it is then pushed upward and inward for about 1 cm. further
into the intercostal space above, and this freely infiltrated. This
procedure is similarly carried out for as many spaces as indicated,

THE THORAX AND BACK 285
taking in two or three spaces above and below the proposed field, as
the lateral branches of these nerves freely overlap.
It must be remembered that the intercostal nerves lie deep down
near the pleura, and the injections must be made well down in the
interCostal spaces; this is best shown by a reference to Fig. 66; punctur-
ing the pleura should be avoided, but if done no damage will result,
only the solution is wasted.
To anesthetize the anterior chest wall in front an injection is made
Subcutaneously over the clavicle to block the branches of the supra-
clavicular nerves as they descend over this bone. This is best done by
making an intradermal station over the middle of this bone, and
passing the long needle Subcutaneously in both directions, injecting
as the needle is advanced until the entire area has been infiltrated.
(See Fig. 67.)
A wall of anesthesia must then be established from the middle of this
bone outward to block the branches of the anterior thoracic nerves as
they descend beneath the pectoral muscles; this must extend from the
skin to the chest wall, and outward as far as the axilla. (See Fig. 67.)
These two last injections, when combined with anesthesia of the
upper intercostals, produce an area of anesthesia of the pectoral
region and underlying chest wall including the pleura.
The removal of a rib along its entire course for tuberculosis, os-
teomyelitis, etc., is fairly satisfactorily done under local methods,
except for the upper ribs, which underlie the shoulder girdle and are
difficult of access, but any of the lower ribs can be easily removed from
their angle forward by blocking the intercostal nerves for about two
spaces above and below; this, combined with a fairly free subcutaneous
infiltration along the course of the posterior thoracic, where this
nerve crosses the rib, will be found to be sufficient. Where several
ribs are involved this procedure will be found very satisfactory, but
where only one is involved through but a part of its course it will be
found that simple infiltration is to be preferred. Starting at the
proximal end of the fields an intradermal station is made over the
rib, and the long needle entered at this point and advanced in the
deep tissues close to the rib, injecting as the needle is advanced, re-
entering it further on if necessary, until the entire subcutaneous field
has been injected; we then return to the skin and finish the injection
intradermally along the proposed line of incision over the rib. The
object in making the deeper injections first is to allow ample time
for the solution to diffuse while making the skin injection and thus
save the necessity of having to wait later.
286 LOCAL ANESTHESIA
Less is known about the sensibility of the parts within the thorax
than about the contents of any other cavity of the body, but it is
believed that the same general rules governing the sensibility of the
abdominal contents hold good here, that is, that the parietal pleura
is sensitive and the visceral insensitive; the same with the pericar-
dium. The lung is said to have no sensation. After the chest walls
and parietal pleura have been anesthetized, an exploring needle can
be passed freely within its substance without complaint, and it can
Fig. 69-1, Method of injecting field for thoracotomy: I and 2, Direction of long
needle to intercostal spaces above and below rib to be resected; 3, crescentic wall of
anesthesia made subcutaneously embracing field; 4, line of incision. 2, Method of
anesthetizing sternal region.
also be sutured to the chest wall without pain. The diaphragm is
usually not sensitive.
The operation of thoracotomy is quite easily performed on almost
any part of the thorax wall. After a consideration of the course of
the nerves, it is seen that an injection proximal to the field of opera-
tion will block all nerves entering the area. Suppose we were to do a
thoracotomy for empyema in the axillary line, with resection of the
seventh rib, a point over this rib and just behind the field is selected
and an intradermal injection made with fine needle. The large syringe
and long needle is now taken, and the needle entered at this anes-

THE THORAX AND BACK 287
thetized point and passed down to the interval between the sixth and
seventh rib, injecting lightly as it is advanced, until the plane be-
tween the intercostal muscles is reached. This can be fairly accurately
determined by placing a finger firmly between the ribs and over the
point of the advancing needle. It should be remembered that the
nerve lies near the lower border of the rib. When the desired point
is reached, about 1 or 2 drams of solution is injected. The needle is
then slightly withdrawn and passed in the opposite direction, in the
space between the seventh and eighth ribs, and a similar injection
made. While we are waiting for the injection to act here, the infiltra-
tion of the skin is finished. This is done rather freely, in a crescentic-
like course, over the sixth, seventh, and eighth ribs, the horns of the
crescent turned toward the operative area (Fig. 69).
The anesthesia resulting from the above injection in the area just
in front should be perfect, including the bone and pleura, and the
Fig. 7o.—Schematic representation of method of anesthetizing rib for resection in
thoracotomy. (From Braun.)
operation can be commenced by the time the skin infiltration is
finished.
In the event that the operative field is slightly in front of the
anterior axillary line a rather free subcutaneous injection is made, in
addition to the above, to meet the anterior divisions of the lateral
cutaneous branches of the intercostals given off at this point. If
preferred, a rib may be resected in any part of its course by embrac-
ing the area by infiltration, which is carried well down into the inter-
costal spaces above and below (Fig. 70). -
Transthoracic hepatotomy for abscess is quite satisfactory under
local anesthesia; the larger and more superficial the abscess the easier
is the procedure. It should not, however, be done without first posi-
tively locating the abscess with an exploring needle, and the needle left
in position while the infiltration is being carried out. This is done the
same as for thoracotomy, either by blocking the nerves or by massive

288 LOCAL ANESTHESIA
infiltration. The rib next below the exploring needle is exposed and
resected for about 2 or 3 inches. If it is found now that the dia-
phragmatic pleura is adherent to the parietal, the incision can be made
at once down to the abscess, along the Course of the exploring needle
which has been left in position. The diaphragm is not usually sensi-
tive, but, if it is found so, a few Small Syringes of Solution, distributed
along the course of the proposed incision, will suffice to control it.
The liver itself is never sensitive. If it is found that the pleural space
is still open at this point, the diaphragm must be sutured to the chest
wall before the abscess is incised. In doing this, if pain is occasioned,
the diaphragm is easily reached with a long needle and infiltrated.
To illustrate the extensive procedures, which are possible under local
anesthesia in this region, we quote the following from a paper by
the author, which appeared in the “Transactions of the Orleans Parish
Medical Society for 1909”:
“The next case is rather unusual, and one of the most interesting
upon which I have ever operated, and, owing to the rare combination
of conditions found, I would like to put it upon record at this time:
“H., admitted to Ward 9, had been suffering from dysentery for several weeks,
having frequent bloody stools, in which amebae had been found. Medical treatment
checked, but did not stop, the bloody evacuations. He shortly developed pain and
swelling over the region of the liver; aspiration showed pus, which again showed the
amebae. He was prepared for operation and the liver again aspirated. No pus was
located, but instead a large quantity of clear fluid was withdrawn from the pleural cavity;
as the patient was very weak the chest was not opened, as I did not think thoracotomy
justified for a serous accumulation. He continued to do badly, so on August 9, 1909,
under local anesthesia, the eighth rib was resected and a large pleural effusion evacuated;
the fluid was now of a sanguinous character. I felt this was not sufficient to account for
the marked sepsis and effusion, as well as the physical signs we had obtained on examina-
tion, so explored further, enlarging the opening in the chest wall for inspection. The lung
was seen bound down to the diaphragm in the middle line, some distance from the chest
wall, and looked and felt boggy. An aspirating needle was passed into it a short distance
and withdrew a thick, white creamy pus. A free incision was then made, opening an enor-
mous pus cavity, which must have contained several pints, and extended in toward the
median line about 8 inches. The incision in the lung caused no pain. Through this open-
ing in the lung I explored the region of the diaphragm. At one point it felt distinctly
fluctuating, and with my finger I broke through the diaphragm, opening a small pocket
of pus of a chocolate color. It was of small size and at rather an inaccessible point, which
explained our missing it the second time with the aspirator. We thus had in this case three
distinct cavities, each yielding a different kind and color of pus. The openings into these
several cavities were all enlarged and made to drain through the common opening in the
chest wall by large-sized drainage-tubes. The operation was entirely without pain. The
different specimens of pus were differently collected and examined and found to contain
an organism resembling the Shiga bacillus, but no amebae. It was possible he was suffer-
ing from a double infection. The only way I can account for this peculiar abscess com-
bination is that the liver abscess ruptured into the lung, and when relieved of its tension
the opening closed. The pleural effusion was a secondary phenomena,
THE THORAX AND BACK 289
Operations upon the breasts for galactocele, fibromas, or other
benign growths, as well as mammary abscesses, when not too diffuse,
can be quite satisfactorily operated by local anesthesia, but for the
radical operation in malignant disease of this gland a general anes-
thetic should be given.
For removal of benign tumors of the breast, when well defined,
the skin infiltration can be begun on the outer side at the base, and
Fig. 71.-For operations upon the base of the female breast, as in the removal of
cysts and benign growths, a crescentic line of intradermal infiltration is produced
around the base and outer side in the sulcus formed by the attachment of the breast
with the chest wall. The breast is then raised, and with the long needle and large
syringe the cellular space beneath the breast is infiltrated in all directions with the
anesthetic solution. The incision is made in the sulcus and the breast turned up and
operated upon from beneath; it is then dropped back in place and sutured, leaving
very little scar visible. If the operative field involve the upper part of the breast
near its cutaneous covering, this upper part should be surrounded by subcutaneous
infiltration to block the supraclavicular nerves. The nerve-supply of the breast is
from the intercostals, which approach it from the outer side and beneath, the anterior
thoracic nerves from above and externally, and the supraclavicular nerves from above,
these latter supplying only the skin and subcutaneous tissue as far down as the nipple.
carried around the base of the gland at its attachment to the chest
wall on its outer and under surfaces (Fig. 71). Before commencing
the skin injection it is well to infiltrate the tissues at the base of the
gland, when the skin infiltration can be returned to and finished, allow-
ing the other opportunity to act, thus saving time. This is done in
the following manner: With a large syringe and long needle, or Matas
infiltrator, the needle is advanced through the anesthetized skin and
directed into the cellular tissue, well under the base of the gland and

19
290 LOCAL ANESTHESIA
mass to be removed; while these are held up with one hand to better
define this space, about 1 ounce of the solution is usually distributed
here, but more may be necessary if the gland and mass are large.
After the skin infiltration has been finished, an incision is made at the
base of the gland, on its undersurface, at its attachment to the chest
wall. The gland is then turned up, exposing its base, when the re-
moval of the mass is accomplished from the undersurface and the
gland dropped back in place and sutured, the resulting scar not being
visible.
Where a simple growth or other lesion is superficially situated
on the surface of the gland, a wall of infiltration anesthesia is created
Fig. 72.-Method of creating a zone of anesthesia around a benign mammary tumor.
(From Braun.)
around and beneath it in all directions after the Hackenbuch plan
(Fig. 72).
The method of dealing with mammary abscesses will depend some-
what upon their location; but, as these usually point superficially,
they are best opened by direct infiltration over their most prominent
point. -
THE STERNUM
This is blocked by making two vertical intradermal lines of anes-
thesia just to the outer side of the costochondral junction, to be away
from the line of the internal mammary; these lines should meet above
and be made subcutaneous here to block the suprasternal branches of
the supraclavicular (see Fig. 69), the long fine needle is then used, and

THE THORAX AND BACK 29I
intercostal injections then made, on each side in the same manner as
already spoken of for blocking these nerves behind. This plan gives
complete anesthesia of this region and the sternum can be resected if
necessary.
Where the field of operation is limited to a small area, either of the
overlying Soft parts or of the chest wall, an area of anesthesia sur-
rounding these parts is ample, as already described.
Operations on the thorax with the above technic have proved very
Satisfactory, and it is the procedure usually adopted by us, but where
preferred simple massive infiltration can be employed, either directly
in the line of the proposed incision or in a crescentic or circular man-
ner, embracing the field and carried from the skin to the ribs, without
regard to the course of the nerves. This procedure, while satis-
factory, requires much more of the solution, which may be objec-
tionable if the operative field is very large.
THE BACK
The surgical affections of this region are rather limited, and consist
chiefly of carbuncles, furuncles, superficially situated growths, such
as epitheliomas, moles, and the removal of an occasional bullet from
beneath the skin; the back is also a favorite site for lipomas and fibro-
lipomas, the latter often attaining a large size and usually peduncu-
lated.
Carbuncles, unless they penetrate too deeply, are quite satisfac-
torily operated upon by local anesthesia; the superficial extent of
the lesion, unless enormous, is not usually a contra-indication, but the
depth to which it extends, should it burrow down into the deep
muscles and be situated over the midline of the back, may prevent
our reaching the nerves at their exit from the spinal canal, except by
going through diseased tissue, which is objectionable; however, the
depth to which lesions penetrate is of no consequence if sufficiently
removed from the midline to permit a long needle to be passed down
through healthy tissue to reach the interval between the ribs.
In patients suffering from carbuncles we often have complicating
constitutional conditions, such as diabetes, nephritis, or profound
Sepsis, which contra-indicate the safe employment of a general anes-
thesia. In these conditions local methods should be given the prefer-
ence if it is possible to employ them.
The nerves of the back are divided into two sets of branches—
anterior and posterior. The anterior branches (intercostals) run down-
ward and forward.
292 LOCAL ANESTHESIA
To block the nerves of the back when to the side of the midline,
the procedure is the same as for operations upon the thorax by block-
ing the intercostals. If the field is high up in the dorsal region, an
additional wall of anesthesia will be necessary above the field, and
should be made well down to the deep muscles to reach any nerves
descending from above.
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If over the midline, the procedure, as indicated in Fig. 74, may be
carried out on the Hackenbuch plan (see Fig. 19), which may also be
used to advantage in any region of the back.
In the lumbar region, except close to the spine, the exact point
of the nerve cannot be determined; it is then necessary to create a
wall of anesthesia in the deep muscles to meet the nerves as they come

























THE THORAX AND BACK 293
through, having the injections surround the field on its inner and
upper parts to meet the nerves as they run downward and for-
ward (Fig. 74) in the thorax between the ribs (see Nerve-supply
of Thorax), in the lumbar region between the deep lumbar mus-
cles (Fig. 73). The posterior nerves run backward, and are dis-
tributed to the soft parts lying on either side of the middle line. We
Fig. 74-I, Hackenbuch plan of anesthesia embracing operative area: Circle of
cutaneous anesthesia first surrounds field; long needle enters at several points on this
circle and is directed obliquely downward and inward infiltrating deep planes. (See Fig.
19.) 2, Method of anesthetizing operative field in lumbar region: Dotted line—extent
and direction of cutaneous anesthesia; heavy dots—points for inserting needle for deep
injections into muscle walls; oblique lines–area of resulting anesthesia; dross-lines—
operative field.
must remember that the area of distribution of any one nerve is
overlapped by the nerves lying above and below it, and in some
occasions, such as the upper part of the thorax, is crossed by nerves
running in a different direction.
By operating in this way, procedures of considerable magnitude
can be satisfactorily and painlessly performed, and often with com-
paratively little solution, but it is necessary, when making para-

294 LOCAL ANESTHESIA
neural injections in this way, to allow a sufficient time to elapse (ten
to fifteen minutes) for the anesthesia to become well established before
beginning the operation. If the operation is near the midline of the
back, a subcutaneous wall of anesthesia, made up and down the back
near the line, will meet and block any overlapping branches from
the opposite side. .
This method of operating will be found very satisfactory in deal-
ing with carbuncles and malignant growths when it is necessary that
the infiltration should not be made into the diseased tissue.
Where the field of operation is somewhat removed from the mid-
line, the depth of the tissues is much lessened and the procedure
simplified. It is necessary here to create a somewhat crescentic-
shaped wall of anesthesia on the proximal side from the surface to
the deep parts, injecting between the ribs, and having the horns of
the crescent to slightly embrace the field of operation, the same as
has been suggested in Fig. 74. *
By the above procedures, we have often operated large carbuncles
or removed growths and have frequently resected ribs, and on one
occasion removed an entire rib for tuberculous disease.
Large pedunculated fibrolipomas, common to the back, can be
very easily removed by local anesthesia by injecting a collar of anes-
thesia in the skin around the base of the growth. After the skin
injection has been started, a long needle is passed deep into the tissues
at the base of the pedicle and from # to 1 ounce or more of Solution.
No. 1 (plus adrenalin), according to the size of the growth, is dis-
tributed in the tissues at the base. While this is being allowed time
to diffuse we can return to the skin injection and complete this, when
the removal of the mass can be easily accomplished. In this way
the author has removed a fibrolipoma about half the size of a water-
bucket from between the shoulders of an elderly gentleman. Of
latter years the size and unsightly appearance of the mass had kept
him indoors, and more recently had almost anchored him to bed. -
º
CHAPTER XVII
THE ABDOMEN
THE question of the sensibility of the contents of this Pandora's
box of the human body, in spite of the many experimental observa-
tions on animals and man and the many daily operations performed
without general anesthesia, still remains largely in doubt, or at least
a much disputed question between the followers of Lennander on the
One side, and those who have arrived at their conclusion as the result
of purely animal experimentation on the other.
Of one thing we are sure, there is nothing more certain or real
than the existence of intra-abdominal pain—peritonitis, appendi-
citis, enteric, biliary and renal colic, etc. Such are daily observations
in the routine of the physician’s work; still, we are confronted with
the statement, as the result of accumulated surgical evidence from
reliable Sources, that the intra-abdominal organs feel no pain, whether
normal or inflamed.
While this subject has been investigated by earlier writers, both
physiologists and surgeons, it had not been given the attention and
study it merited until undertaken by the late K. G. Lennander, who
made a most careful and thorough investigation, publishing his
results in 1901, and since that date up to the time of his death. His
conclusions were briefly that the parietal peritoneum is intensely
Sensitive to pain, but not to pressure, heat, or cold; this sensibility is
increased by inflammation; the visceral peritoneum and abdominal
organs are entirely devoid of any sense of pain, even when inflamed,
and may be cut, crushed, torn, or burned without exciting pain; in
other words, that all pain arising from disturbances within the ab-
domen is caused by irritation through spread of inflammation to the
abdominal walls or pressure exerted upon these parts innervated by
the cerebrospinal system, and that those parts supplied by the vagus
and sympathetic system of nerves have no afferent fibers for the
transmission of painful impressions. While Lennander's findings
for the mesentery were not positive, he considered it also insensitive
to any irritations or manipulations, except pulling upon it, which
naturally exerted tension on the posterior abdominal wall and ex-
295
296 LOCAL ANESTHESIA
cited pain. Other investigators have stated that the occasional
production of pain in the mesentery, as observed during operations
upon man, may be due to the presence of an occasional cerebrospinal
nerve, which may have found its way into these parts through an
anomalous distribution. This view, however, is not satisfactory.
Nothnagel has attributed the pain of intestinal colic to an anemia of
the intestinal walls and pressure exerted upon the nerves of those
parts through the violent muscular contractions; Wilms, on the other
hand, accounts for the same pain by the violent peristalsis producing
a stretching of the mesenteric attachments. Lennander, in in-
vestigating the same subject, found that he could stimulate a loop of
the human intestine to such a degree that it became hard and anemic,
without the production of pain until the mesentery was pulled
upon. The last paper from Lennander's pen, which gives his views
on this subject, was read at the meeting of the Amer. Med. Assoc.,
1907, and is as follows:
“From my published works it may be gathered that I have not
been able to find any abdominal organ, innervated only by the vagus
or the sympathetic nerves, which is provided with the sense of pain.
Sensations of pain within the abdominal cavity are, according to my
experience, transmitted only by the phrenic nerve, the lower six
intercostal, the lumbar, and the sacral nerves.
“My former pupil, M. Ramström, professor of anatomy at Upsala,
has given us the first exact description of the course of these nerves
within the diaphragm and the peritoneal lining of the anterior ab–
dominal wall. He has shown that some of the older descriptions of
the distribution of these nerves are incorrect.
“For instance, he has not seen any branches of the phrenic nerve
running down from the diaphragm to the anterior abdominal wall,
nor has he been able to trace a single branch of the phrenic nerve
through the suspensory ligament to the capsule of the liver. Simi-
larly, he has been unable to find any twigs from the intercostal nerves
of the diaphragm which extend to the capsule of the liver.
“These anatomic observations of Ramström agree with my own
experience in regard to the sensitiveness of the liver. Even a strong
faradic of galvanic current, applied to the surface of the liver above
the gall-bladder, does not excite pain. In some cases, in which the
position of the liver was low, I have separated the attached surface
of the gall-bladder as far as the cystic duct without causing any pain,
whereas the patient complained as soon as I tilted the liver or dragged
on the common bile-duct, thus putting the cerebrospinal nerves of the
THE ABDOMEN 297
abdominal wall on the stretch. Not only the sense of pain, but also
the other modalities of sensibility—pressure, cold, and heat—are absent
from the liver and gall-bladder as well as from the stomach and in-
testines.
“We have often been able to ascertain that viscera involved in dis-
ease are quite as insensitive to operative measures and to electric
stimuli as are sound ones. Thus, the old theory defended by Flourens.
has been destroyed.
“After many investigations—some of which have been attended
by the well-known physiologist, Hj. Ohrvall, and several by Professor
Ramström as recorder—we had come to the conclusion that the
parietal peritoneum of the anterior abdominal wall possesses only
the Sense of pain, not the senses of pressure, cold, and heat. (In
most cases it was the peritoneum behind the recti muscles, from a
point 4 to 5 cm. above the umbilicus to a point midway between the
umbilicus and the Symphysis pubis, which had been examined.)
Should this view of ours prove correct, it speaks decidedly in favor
of the Specific character of the nerves of pain. In other words, it goes
to prove that the entire parietal peritoneum is provided only with
nerves of pain—a condition previously known to exist in the cornea
alone. -
“It is my opinion that all painful sensations within the abdominal
cavity are transmitted only by means of the parietal peritoneum
and its subserous layer, both of which are richly supplied with cerebro-
spinal nerves around the whole of the abdominal cavity, possibly with
the exception of a small area in front of the vertebral column lying
below the crura of the diaphragm and between the two chains of
sympathetic nerves. Here, as far as I am aware, no cerebrospinal
nerves have as yet been demonstrated, and on a few occasions I have
observed that within this area the patient does not respond to hard
pressure with a finger or with an instrument; nor, furthermore, does
he experience any sensation when a small portion of the mesenteric
attachment at this point is put on the stretch.
“The opportunity is given during operations of observing that
the manipulations which cause pain are those which occasion stretch-
ing of the parietal peritoneum as well as of the parietal attachments
of the mesenteries. For example, pain is occasioned by the placing
or removal of gauze compresses between the viscera and the parietal
peritoneum, by the dragging forward of the cecum, of the vermiform
appendix, or of any other organ whose normal attachment to the
abdominal wall is put on the stretch; and the same principle applies
298 LOCAL ANESTHESIA
to the stretching of any abdominal adhesions which may connect the
viscera with the abdominal wall. On the other hand, should a com-
press lie between the viscera without coming in contact with the ab-
dominal wall, the patient experiences no sensation when it is removed.
Similarly, no sensation attends the stretching or breaking up of adhe-
sions which have no connection with the abdominal parietes. As
far as I can judge from my observations, the parietal peritoneum
along the thoracic aperture and around the foramen of Winslow is
especially sensitive to stretching, displacement, etc.
“A slow and gradual stretching of all the layers of the abdominal
wall by ascites or meteorism occasions distress rather than pain, al-
though a high degree of meteorism may be attended by great dis-
comfort. If in a severe case of paresis of the bowel one succeeds in
emptying the intestine by means of a typhilitic, a jejunal, or gastric
fistula, the procedure is followed by such evident relief that the dis-
tress of the previous condition is emphasized. That a maximum
degree of rapidly forming meteorism is an extremely painful condi-
tion, and one which may rapidly endanger life, I have witnessed in the
case of a young student who had a coincident volvulus of the ileum
and acute dilatation of the stomach. Four hours and a quarter after
the appearance of the first symptoms he was pulseless from intense
pain attended with a sensation of bursting.
“Infectious processes involving the abdominal viscera (ulcerations,
acute inflammations, etc.) are attended by lymphangitis and lymph-
adenitis of the mesenteries. The infection spreads along the lymph-
vessels to the Subserous tissue of the abdominal wall, and, inasmuch
as the lymph-vessels follow the course of the arteries, the lymphangitis
very soon reaches the sides of the aorta, along which it then may con-
tinue up to the thoracic cavity. A lymphangitis of the parietal
Subserous connective tissue greatly increases the sensitiveness (ex-
citability) of the cerebrospinal nerves to any manipulation which
occasions pain even under normal circumstances.
“All that we know of lymphangitis and lymphadenitis attending
affections of the mouth, of the pharynx, of the extremities, etc., ap-
plies equally well to corresponding processes within the abdominal
cavity. We know, for example, that the severity of pain attending
a lymphangitis and lymphadenitis of the above-named regions varies
according to different infections, and the same thing is true for the
abdominal cavity.
“The irritability of the nerves of pain of the parietal peritoneum
is much increased even by the slight peritoneal inflammation. In
THE ABDOMEN 299
the case of a serous peritonitis (peritonale, Reizung) the boundaries
of the hyperemic zone of the parietal serosa can be mapped out almost
to the centimeter by gentle palpation of the abdominal wall. With
further increase of the hyperemia and of the inflammation the sensi-
tiveness is at first almost proportionally increased. The fact that so
many infectious processes within the abdominal cavity begin with
diffuse abdominal pain may be explained by (1) an increased sensi-
tiveness of a large portion of the parietal peritoneum, owing to the
lymphangitis or peritonitis; (2) a considerably increased irregularity
of peristaltic action which, in addition to pain, often produces a feeling
of sickness, vomiting, and one or more actions of the bowels at the
commencement of these illnesses. On account of the increased sensi-
tiveness, the movements of the stomach and intestines against the
parietal peritoneum and the stretching of their respective mesenteries
are felt as Severe pains. In most cases, however, the general peritoneal
irritation soon passes off. Only the part more especially infected
remains in a condition of inflammation, and the abdominal pain will
become localized at this spot. In those cases where the infection
spreads over a large portion of the peritoneal cavity, thus giving rise
to a more or less general peritonitis, the pain will diminish as Soon
as the bowel becomes paretic and the nerve-endings of the parietal
peritoneum have been more or less destroyed by the severe inflam-
mation.”
“Pain in Connection with Perforation.—In case of visceral per-
foration or of an abscess which ruptures into the free abdominal
cavity, the primary pain is caused by the contents of the organ, or of
the abscess, coming into contact with the parietal peritoneum. The
severity and character of the pain depends on the nature and quantity
of the escaping fluid, the extent to which it immediately comes into
contact with the parietal peritoneum, and, lastly, on the intensity of
the contractions of the stomach and bowels brought on by the irrita-
tion of the peritoneum.
“Many clinical observations are explicable if one bears in mind
the fact that only the parietal peritoneum can transmit painful
sensations. For example, the primary pain occasioned by a duodenal
perforation may be referred to the iliac fossa. Again, the paroxysmal
pains in connection with a gastric ulcer are elicited by the movements
of the stomach; that is to say, by its dragging on a parietal Serous
membrane which is hyperesthetic on account of a lymphangitis from
an infected ulcer. If the stomach is put at rest by the aid of a jeju-
nostomy the pains cease. Further, in the case of a patient with an
3OO LOCAL ANESTHESIA
inflammatory focus, surrounded by small intestine and covered by a
thick omentum, pressure on the abdomen will disclose no tenderness,
whereas palpation per rectum may cause pain.”
“The Hypotheses of Nothnagel as Regards Colic.–In human
beings suffering from intestinal fistulae, and to whom no anodyne
has been given, sensation of pain cannot be evoked by means of
chemical, thermic, mechanical, or electric stimuli applied to a portion
of the gut lying outside the abdominal cavity as long as the stimulus
or contractions which it causes only affect the bowel. When, on the
other hand, the contracting bowel drags on adhesions connecting it
with the abdominal wall it at Once produces pain.
“Both theories of Nothnagel are hereby disproved, for the colicky
pain cannot be due to pressure on the nerves of the bowel wall in
consequence of a tonic spasm of its muscular coat, since the intestinal
wall can be crushed with a strong pair of forceps without eliciting
any sensation whatsoever. Further, the pain cannot be due to anemia
of the intestinal wall due to a spasm of its muscular coat, since it is
possible by means of electric stimulus to produce so powerful a con-
traction of the bowel that it becomes of tumor hardness and assumes
a yellowish-white color from anemia, without the patient experiencing
any sensation, even of being touched.
“Wilms, in an article and later in his splendid work on ileus (1906),
tried to show that all those pains which we are accustomed to term
‘intestinal colic' are entirely due to stretching of the mesenteric
attachments. In my first publication (1961) I made the statement
that every distention or contraction of a gut which is attended by a
pull on its attachments to the abdominal wall is necessarily painful,
as it involves a stretching of the cerebrospinal nerves of the parietal
serous and subserous layers. With regard to the duodenum, the
duodenojejunal flexure, the three flexures of the large intestine, and
the most distal part of the ileum, it goes without saying that these
portions of the bowel cannot contract on their contents in front of an
obstruction without giving rise to a powerful dragging of their mesen-
teries, and at the same time a painful stretching of the nerves of sensi-
bility of the parietal serosa. In similar fashion, powerful intestinal
contractions are bound to involve a painful stretching of the parietal
serosa in case the bowel has become fixed to the abdominal wall by
adhesions, and there exists at the same time some obstruction at
this point.
“The pains in connection with ileus, due to kinking, volvulus, etc.,
were thus easy to understand. On the other hand, it was my opinion
THE ABDOMEN 3OI
that the stretching of a high and free mesentery of the small intes-
tines or of the transverse colon could not account for the pain attend-
ing a stricture of these parts of the bowel when the stricture has not
become adherent to the abdominal wall or in some way fixed, be-
Cause I could not think that a contraction of the bowel around its
Contents in front of the stricture could drag on the parietal serosa
and Subserosa by that high and free mesenterium. Wilms also ac-
Counts for the pain in these cases as being only the result of the stretch-
ing of the mesentery proximal to the stricture. He considers that a
loop of bowel, contracting on its contents at the proximal side of a con-
striction, endeavors to assume a straight form in the same way as
does the gut in Sausage-making. The mesentery, however, prevents
the bowel from assuming the shape of a straight cylinder. The result
is a stretching of the mesentery, and this is what causes the pain.
In this connection, an observation was made a year ago in a case in
which I had to resect more than I meter of the ileum, together with
the cecum and a large portion of the colon, this portion of the intes-
tine having been excluded some months previously by means of an
ileocolostomy, on account of multiple fistulas and adhesions which
could not be loosened.
“Under local and a short ether anesthesia the excluded portion
of the bowel was completely freed from all adhesions, only the normal
mesenteric attachment being left; the patient being awake, a piece
of the ileum, about 40 cm. long, was clamped and inflated with air.
The bowel straightened, the mesentery got stiff and assumed a fan-
shaped form. While in this position, standing out from the vertebral
column, the patient complained of pain, but this passed off as soon
as the bowel was emptied of air and the mesentery was allowed to
resume its normal position. The experiment was repeated with a
considerably shorter piece of bowel. The result was the same, for the
mesentery again became tight and stood out from the vertebral col-
umn, occasioning pain. Lastly, a piece of the intestine, only 5 or 6 cm.
long, was shut off. Although it was inflated ad maximum, causing
the serous membrane to burst and the bowel to sink between the two
layers of the mesentery for fully I cm., the patient felt nothing. As
soon, however, as the mesentery was stretched for a few moments
with the fingers pain was felt. These observations are in full accord-
ance with the above-mentioned view of Wilms as regards the stretch-
ing of the mesentery, a view which I believe to be correct.
“The pain in connection with a volvulus of the intestine or of
an ovarian cyst naturally increases in proportion as the twisting
3O2 LOCAL ANESTHESIA
comes on quickly and more parietal peritoneum is drawn into the
pedicle.” -
“Pain Caused by Displacement of the Serous Membrane of the
Anterior Wall.—On many occasions, when performing a laparotomy,
I have passed into the abdominal cavity a finger, covered with a thin,
smooth Indian rubber glove, dipped into Saline Solution, and exerted a
slight pressure on the anterior abdominal wall. Of this the patient
has no perception, but as soon as the Serous membrane is displaced
against the muscles or aponeuroses of the abdominal wall the patient
has a feeling sometimes of touch, more often of pain, according to
lesser or greater sensitiveness of the individual, and according to
the degree of pressure and displacement employed. When asking
the patient, ‘Have you ever felt anything like this?' I have usually
received such answers, ‘It feels like colic’; ‘It feels as if the bowel is
being expanded by wind’; ‘It’s like bad griping pains’; ‘It’s worse
than gripes.’
“Such sensations are occasioned by displacing a small, limited
area of the serous membrane at nearly any point of the anterior
abdominal wall. On account of these observations, I believe that a
displacement of the serous lining takes place and gives rise to pain
as soon as a loop of intestine contracts on its contents, hardens, rises,
and presses against the parietal peritoneum. According to my opinion,
these pains occur not only in connection with ileus, but also in con-
nection with temporary irregularities of the peristaltic movement of
the bowels in people not suffering from abdominai diseases. I have
myself felt these griping pains, and I have been strongly inclined to
localize the same at the anterior abdominal wall, most often to the
left lower quadrant. As a rule, I have attributed them to the con-
tractions of the sigmoid flexure. -
“Here I may mention a case illustrating the displacement of the
serous membrane of the anterior abdominal wall at the thoracic aper-
ture. It was brought about by a subserous myoma of the uteri of
about the size of a mandarin in a woman eight or nine months preg-
nant. She had suddenly been taken ill with severe pains, vomiting,
and inability to pass flatus. A diagnosis was made by her medical
attendant of a twisted ovarian cyst. As soon as the myoma had been
removed under the local anesthesia all symptoms disappeared. The
ovaries were normal. The pregnancy went on to its normal termina-
tion. I have record of another patient, who had a small subserous
myoma of the uterus, and in whom, after the seventh month of preg-
nancy, abdominal pains were produced by any movement. They
THE ABDOMEN 3O3
were felt as a very painful friction, and disappeared as soon as the
tumor was removed.
“If the bowel wall on the proximal side of an obstruction is con-
siderably thickened and the serous coat rough, the ‘Darmsteifung' is
naturally attended by a much more extensive displacement of the
parietal peritoneum than in the case of a normal intestinal wall.
Contrary to Wilms, I consider this factor also to be the cause of the
colicky pain which attends intestinal obstruction. I have, conse-
quently, come to the conclusion that “gripes' are due partly to a stretch-
ing of the parietal attachments of the bowel and partly to a displace-
ment of the Serous lining of the abdominal wall.”
“Reflex Rigidity of the Abdominal Muscles.—The normal re-
Sponse of the abdominal muscles to an acute sensation of pain which
originates in the parietal peritoneum or subserous tissue lies in a
reflex contraction (défense musculaire). In case of violent and very
extensive irritation (hyperemia, slight edema) the abdomen assumes
a board-like rigidity and the respiration becomes costal in type, for
the abdominal muscles and the diaphragm are in a state of tonic
Contraction. In this way the range of movement of the abdominal
organs is greatly diminished, and consequently the abdominal pain is
greatly lessened. Compare with this the endeavor of patients suffer-
ing from Severe abdominal pains to get relief by lying on the ‘belly,” or
by fixing Something tightly round the abdomen. The extension of the
reflex muscular rigidity corresponds closely to the area of peritoneal
irritation of the parietal serosa. We know little as yet about défense
musculaire in connection with a mechanical ileus before the onset of
peritonitis. It is necessary to observe with care every case of severe
colicky pain attending an intestinal obstruction, in order to see whether
a tonic contraction of the abdominal muscles and diaphragm takes
place, with the object of diminishing the movements of the bowels
and indirectly the severity of the pains.
“In acute inflammatory diseases of the abdomen I have not ob-
served the presence of cutaneous hyperalgesia so often as one might
expect, especially in consideration of the ‘triade douloureuse' of
Dieulafoy (1899), which he regarded as necessary for the diagnosis
of an acute appendicitis—cutaneous hyperalgesia, reflex muscular
rigidity, tenderness on pressure. Before applying Head’s theory of
cutaneous hyperalgesia to a given case, one ought to consider the
question whether in that special case an infectious lymphangitis,
along the posterior abdominal wall and around the vertebral column,
3O4 LOCAL ANESTHESIA
might not cause a hyperesthesia of the sensitive nerve-trunks and
spinal ganglia of that region.
“It will, of course, be clear to every one that this is only a work-
ing hypothesis. In those few cases of acute appendicitis with cuta-
neous hyperalgesia, which have come under my care since I began to
pay more attention to this matter, I have observed co-existing tender-
ness on deep pressure in the angle between the twelfth rib and the
erector spinea or somewhat lower down at the border of this muscle.
“When considering the pains connected with infectious diseases
of the liver and gall-bladder, one has to remember that well-known
embryologic facts, as well as my own researches and the investiga-
tions of Ramström, all lead to the assumption that the liver, the gall-
bladder, and the extrahepatic bile-passage do not possess nerves of
pain. One has further to consider the distribution of the lymph-
vessels from these organs to the posterior abdominal wall and dia-
phragm, as well as their anastomoses with the lymphatics of the
duodenum and pancreas. One can then easily understand that in-
fectious diseases of the liver and gall-bladder are apt to be followed
by spasms of the diaphragm, and that the movements of the common
bile-duct, the duodenum, and stomach may be attended by pain.
When the gall-bladder contracts spasmodically in order to expel its
contents there results a stretching of the cystic and common bile-ducts,
and consequently a displacement of the parietal peritoneum and the
extremely sensitive retroperitoneal connective tissue around the
common bile-duct. If a tube has been fixed (water-tight) into the gali-
bladder in a case of cystotomy for cholecystitis, Ioo c.c. or more of
Saline Solution may be made to pass from the gall-bladder into the
duodenum (the biliary passage being free) without the patient feeling
anything So long as the Solution is being slowly injected into the gall-
bladder. If the injection is made with a little greater force, the patient
almost immediately complains of colicky pain in the back.
“With a shrunken gall-bladder and very wide common bile-duct,
biliary colic, due to the stretching or distension of the common bile-
duct, is inconceivable.
“It is quite necessary to consider carefully the account which
the patient gives of his pain. Lately a patient of mine, suffering from
an acute hemorrhagic pancreatitis, stated that the attack of pain
began with a sensation as if the large blood-vessel at the back had
burst near the pit of the stomach. The autopsy showed, in addition
to the pancreatic hemorrhages, a large retroperitoneal extravasation
around the celiac artery and the aorta. One must never forget how
THE ABDOMEN 3O5
difficult it is to localize pain, and how great an extent a correct inter-
pretation of the site of painful sensation is a matter of practice.”
“Summary.-In estimating abdominal pain, and especially in
connection with illnesses giving the symptoms of ‘ileus,' we must
bear in mind, briefly, that:
“(i) Pains do not originate within the abdominal organs, which
are supplied only by Sympathetic fibers and the vagus nerves.
“(2) All pains originate in the abdominal wall, more especially
in the parietal serous membrane and subserous connective-tissue
structures which are innervated by the cerebrospinal nerves.
“(3) Stretching of the parietal (mesenteric) attachments of the
stomach and intestines, as well as of string- or band-like adhesions
to the abdominal parietes, invariably elicits pain.
“(4) The same thing holds true for the displacement of the parietal
Serosa from its normal relation to the muscles or aponeuroses of the
abdominal wall.
“(5) Most of the diseases connected with ileus are, at their com-
mencement, attended by increased and, as a rule, irregular peris-
talsis.
“(6) Chemically different substances, such as the contents of the
stomach, gall-bladder, intestine, or abscesses, give rise to severe
pains when they come into contact with a healthy or hyperemic
parietal peritoneum (pain due to perforation).
“(7) Even that form of acute peritonitis which goes under the
name of peritoneal irritation (peritoneale, Reizung) greatly increases
the sensitiveness of the parietal serous membrane. . .
“(8) The sensitiveness of the parietal peritoneum at first increases
pari passu with the inflammation, but later decreases again when the
inflammation has reached a certain high degree, and in many cases
may ultimately cease altogether. (Compare herewith erysipelas
of the skin, more especially the gangrenous kind.)
“I believe, finally, that we are on the way to completely under-
stand the pains of ileus, though a great amount of work still remains
to be done. I consider it to be a very happy thought to bring to-
gether anatomists, physiologists, physicians, and surgeons for the dis-
cussion of this question, and I feel not only greatly honored, but
also deeply grateful, for the invitation to contribute this introductory
paper.”
Lennander's views have been largely confirmed and accepted by
many surgeons the world over, although there still remains some
observations which cannot be satisfactorily explained from his stand-
20
306 LOCAL ANESTHESIA
point. On the other hand, the character and standing of those op-
posing these views, and the highly scientific nature of these experi-
ments, safeguarded by controlling or eliminating every possible avenue
of chance, accident, or doubt in their experiments, almost forces con-
viction.
The latest investigations in this direction have been by Kast and
Meltzer, at the Rockefeller Institute, New York. In a large number
of experiments, mostly upon dogs (but also cats and rabbits), they
have proved in a most convincing way that Lennander's views are
in error on almost every point, at least in So far as they concern these
animals. They further made the astounding revelation that the
amount of cocain used in the infiltrating solution for Operations upon
animals (most previous observations, both on animals and men, had
been made after exposing the abdominal contents under local anes-
thesia) was sufficient in animals to control through its central action
all sensation of intra-abdominal pain. This observation becomes the
more important and interesting when it is remembered that the
general sensibility over the entire body has been so inhibited, through
the central action of cocain, as to permit the painless or almost pain-
less performance of operations. (See chapter on General Anesthesia
with Cocain.) Kast and Meltzer also found that through the injec-
tion of a moderate dose of cocain given in any convenient part of the
body the whinnying, restlessness, and excitement of the animal fol-
lowing the operations under general anesthesia were at once stopped,
the animal becoming quiet, and to all appearances remaining in a nor-
mal condition.
A thorough appreciation of this subject by the reader, as well as
the difficulties in drawing conclusions from the conflicting evidence,
can best be obtained after a review of the facts presented by each
side. The following, “On the Sensibility of the Abdominal Organs,”
by Kast and Meltzer, appeared in the “Medical Record,” December
29, 1906. -
The animals were well narcotized by ether, the abdomen opened,
and immediately closed by temporary ligatures held together by
clamps, and when the animal was partly out of the anesthesia one
or more of the clamps were taken off, thus permitting one or more of
the intestinal coils to come out. These, as a rule, were kept moist and
covered with towels saturated in warm saline solution. In other
cases the entire animal was kept in a saline bath at 39° C., the viscera
being well covered with a warm saline solution. In still other animals
the abdomen was opened under local (cocain) anesthesia.
THE ABDOMEN 3O7
The presence of sensation of pain was tested by pressing the organs
with the fingers or with thumb forceps, by touching them with heated
test-tubes, and by stimulating with the faradic current, and watching
the reaction of the animal to these irritations.
In all stimulations great care was taken to avoid pulling the
mesentery or touching the parietal peritoneum. They write:
“We have tested the various parts of the gastro-intestinal canal—
the spleen, the kidneys, uterus, bladder, etc.—but our present state-
ment refers essentially to the gastro-intestinal canal, which we have
studied mostly.
“All experiments lead up to one unmistakable result, which can
be stated in a few words—the normal gastro-intestinal canal possesses
the Sensation of pain. But, besides the difference in the subject of
observations, there was a difference in the condition under which
both observations were made. Lennander operated essentially under
Schleich's infiltration anesthesia. Schleich's mixture, as Lennander
employed it, consisted of 5 cg. of cocain, I cg. of morphin, and 200 c.c.
of a normal salt solution. *
“It seems advisable to us as a further step in our investigation
to study the possible effects of these ingredients upon the sensation
of pain in the abdominal organs.
“We began with cocain. The hitherto known effect of this drug
was its local anesthetic effect.
“Lennander and other surgeons employed it for this very quality
to deaden the pain during the incision, apparently without the remot-
est idea that the drug could also effect the sensibility of the distant
isolated gut.
“We nevertheless decided to test it. After establishing the un-
doubted sensitiveness of the intestines, etc., 2 cg. of cocain were
injected into the tissues of the abdominal walls near the incision.
We were then surprised, indeed, when we discovered that a short time
after the injection all sensation disappeared from the intestines.
Even a very strong electric stimulus no longer produced any reaction
or effect. After thirty or forty minutes the sensation returned. Such
observations were then repeatedly made, and invariably with the
same results.
“Now, we could hardly think that the cocain crept over by capil-
larity or by some other manner to the intestines, and the observed
anesthetic effect was a local one. Neither did it seem probable that
the cocain crept along the spinal nerves to the spinal cord, and then
came in contact with the pain-carrying nerve-fibers from the intes-
3O8 LOCAL ANESTHESIA
tines. The most reasonable explanation was that the anesthetic
effect was produced through the circulation. That would mean that
cocain had not only a local but also a general anesthetic effect. This
assumption was easily tested. -
“The cocain was now injected in parts distant from the abdominal
cavity, in the thigh, arms, pectoral muscles, etc. The anesthetic
effect upon the intestines was prompt and complete just the same.
“In further experiments, we have established that I cg. was suffi-
cient to bring about the desired effect, and this even in large dogs
weighing 14 kilos. t -
“We have, then, thus far established two facts: that the gastro-
intestinal canal possesses the sensation of pain, and that the subcu-
taneous or intramuscular injection of a comparatively small dose of
cocain is capable of abolishing this sensation for Some time.
“We believe that we are now justified in offering the following
interpretation of the surgical observations: While we have not the
slightest doubt of the correctness of the facts, namely, that when
operating under Schleich's infiltration anesthesia the abdominal organs
are completely anesthetized, we suggest that this anesthesia is due
essentially to the general effect of the cocain employed, and not to a
normal absence of Sensation in these organs.
“In the course of the investigations we exposed some intestinal
coils to the drying effect of the air in order to bring on some inflam-
mation, and we then found that inflamed organs are distinctly more
sensitive than normal ones. In fact, the sensitiveness is often greater
than that of the skin.
“Now, Lennander and other surgical observers stated that in their
experiences also inflamed organs are completely anesthetic. We have,
therefore, tested the effect of cocain upon the exaggerated sensitive-
ness of inflamed intestines, and found that a somewhat larger dose
of cocain, say 3 cg., will completely abolish all sensations also from
inflamed organs.
“Another interesting point is the observation that the parietal
peritoneum also loses its Sensation by a hypodermic injection in any
part of the body, but the anesthesia sets in here later and disappears
earlier than in the internal organs.
“It is possible also that the degree of the anesthesia is less, but
we are not yet ready to make any positive assertion on that point.
“An interesting and new fact is the observation which we made
on the effect which the injection of a small dose of cocain exerts
upon the psychic condition of the animal—it promptly quiets excite-
THE ABDOMEN 3O9
ment. The animals, which were very restless, howling and crying,
became perfectly quiet one or two minutes after an intramuscular
injection of cocain. It may be claimed that the quietness was due
to the abolition of the pain. .
“We have tested it on etherized, but not operated, dogs. On awak-
ening from ether they howl just as much as operated animals; the
howling is not due to pain, but to the ether intoxication. An injec-
tion of cocain quiets them promptly.
“The psychic effect seems to last longer than the anesthesia of
internal organs. The injection has no narcotic effect; the animal is
apparently wide awake and follows one with his eyes. The lid reflex
is not abolished, but the cornea is anesthetic and the pupil is widely
dilated.
“Whether the general sensibility is also reduced, that question we
are not yet ready to answer.”
Still more disquieting than the foregoing to the earlier accepted
views of Lennander appears a later paper by the same careful, thor-
ough, and painstaking investigators on the sensibility of the abdominal
organs, which appeared in the “Mitteilungen aus den Grenzgebieten
der Medizin und Chirurgie” for 1909. As this most interesting and
instructive paper is a highly valuable contribution to this, as well as
collateral subjects, we hope the reader will pardon our quoting from
it at length in the author’s own words: -
“The surgery of our day denies the sensibility of all the abdominal
organs, notwithstanding numerous daily experiences to the con-
trary; this question of normal sensibility belongs to the domain of
physiology. But we find here that for a decade nobody has paid any
attention to the subject, and most text-books do not mention a single
word on the subject. But it was not always thus—in the first half
of the last century many prominent physiologists had contributed
to the Solution of this question. The sympathetic ganglions and the
nerves distributed from them were studied in the range of the ex-
aminations. The results were far from satisfactory and full of con-
tradiction. Many observers asserted in a positive manner that no
kind of irritation of the sympathetic ganglions, their nerve-fibers,
or the intestines was capable of producing pain. Other authors, on
the contrary, equally well known in the history of physiology, as-
serted that strong irritation of these parts was followed by severe pain.
“Megendie stated that cutting, tearing, etc., of the ganglions
made no impression upon the animal.
“Bichat has also reported that a dog had eaten its own exposed
3IO LOCAL ANESTHESIA
intestines, and many other well-known authors have reported similar
observations. Bichat further reported irritating the celiac plexus and
intestines of a dog by cutting or with acid without producing pain.
Johannes Müller, on the other hand, states that mechanical and
chemical irritation of the celiac plexus or the connective tissue of the
renal vessels in the guinea-pig undoubtedly caused pain. Similar
observations were made by Budge, Gianuzzi, and others. Again,
other investigators, among them such brilliant names as Flourens,
Longet, Brachet, and Valentine, take a middle ground. Some stated
that only very strong or long-continual irritation caused pain, and
then of a mild degree. Others had pointed out that immediately
after the exposure of the ganglion by no kinds of stimuli could pain
be produced, but that, on the contrary, after longer exposure, when it
had become red or ‘otherwise irritated,’ the same stimuli were fol-
lowed by manifestations of pain.
“Since the middle of the last century, since which time practical
surgery as well as physiologic experiments have made use of general
anesthesia, we scarcely meet a report on investigation which deals
with our subject. They deal principally in consideration of other
problems in relation to the sympathetic nervous system of the ab-
domen, in which occasionally observations are mentioned which
show that even in narcosis the cutting, crushing, or tearing out of
the splanchnic nerves or the celiac ganglion always cause pain
(Haffter, Nasse, Braam-Heuckgeest, etc.).
“In numerous examinations, undertaken without regard to sen-
sibility, afferent nerve-fibers of the sympathetic were demonstrated
which serve many reflex purposes, as vasomotor, cardiac inhibition,
respiratory, etc. In relation to the sensibility to pain of the abdominal
organs we find the physiologic literature of the last decades, as far
as we are acquainted with it, to contain not even occasional observa-
tions. Some authors, as Buch, Richet, etc., who have concerned
themselves with our problems, admit that these organs normally
possess no sensibility, but that these organs can become the seat of
intense pain when inflamed or otherwise in a condition of abnormal
irritability.
“In recent times the study of the sensation of the abdominal
organs has been undertaken by Surgeons. An occasional clinical
statement regarding the lack of sensibility of the abdominal contents
is met in the older literature here and there.
“Such observations were: the apparent lack of sensibility of the
contents of herniae to mechanical or electric irritation; or of loops of
THE ABDOMEN 3II
the bowel fixed outside the abdominal wall for the purpose of creating
an artificial anus; also of prolapsed portions of intestines.
“Since the introduction of local anesthesia and Schleich's infiltra-
tion method numerous extensive abdominal operations have been
undertaken without general anesthesia; these offered apparently a
very favorable opportunity for the study of our problems. In fact,
many Surgeons have made the occasional observations that the ab-
dominal contents appear devoid of any sensation.
“Bier has stated that the intestines can be cut, squeezed, burned,
etc., without producing pain, but in a later contribution he adds
that tearing the intestines or the connective tissue of the mesentery
or separating adhesions will occasion pain.
“The question was gone into systematically and studied with
greater care by K. G. Lennander. The results of his investigations
were that the intestine, stomach, omentum, mesentery, spleen,
liver, gall-bladder and bile-passages, etc., in short, all organs which
received their nerve-supply exclusively from the sympathetic, possess
neither pain nor tactile or thermic sensations; and this applied not
only to the normal condition, but to the inflamed state as well.
“These organs, asserts Lennander, possess simply no fibers for the
transmission of touch, temperature, or pain. Only the parietal perito-
neum feels pain, and this because it is supplied with spinal nerves.
Inflammation increases the irritability of the nerves in general, and
increases, therefore, the sensibility of those in the parietal peritoneum.
Lennander refers the origin of the different kinds of pain which occur
in the abdomen to the parietal peritoneum and to the spinal nerves
in general.
“Therefore, would a distention of the intestines and intensive
peristalsis produce pressure and rubbing upon the parietal perito-
neum, or by producing a stretching of the mesentery which is felt
on the spinal nerves or the root of the mesentery?
“In consequence of the inflammation of the abdominal organs
there occurs, as Lennander also assumes, not only an increased irri-
tability of the spinal nerves, but also the production of lymphangitis,
which later extends to the tissues which are richly provided with Spinal
Iner VeS.
“Infectious, toxic, or chemically irritating materials, therefore,
occasion pain; they are absorbed through the lymph-vessels, and are
immediately transported to parts supplied by the afferent spinal
Iner VeS.
“Lennander's views are at present shared by many prominent
3I2 LOCAL ANESTHESIA
surgeons, among others von Wilms, who, on the contrary, sees in the
stretching of the mesentery the essential factor in the production of
abdominal pains.
“The most essential and most striking feature in Lennander's
views are that the abdominal organs, which receive their nerve-supply
exclusively from the sympathetic, are entirely incapable of feeling the
sensations of pain, pressure, heat, or cold.
“This view has recently obtained physiologic sanction, and has been
completely accepted by Thunberg in the chapter on Tactile Tempera-
ture and Painful Sensation in Nagel's ‘Handbook of Physiology.’
“Some time ago we began a series of experiments on animals to
determine the sensation of pain in the abdominal organs. Our ob-
servations led us to the following conclusion: The abdominal organs are
capable of painful sensation in the normal condition as well as in the
presence of inflammation. At the same time we made the observa-
tion that this pain disappears after an injection of cocain given in any
convenient part of the body. In publishing a preliminary report on
these facts we consider our ability to put the question, whether or not
in operations on man the cocain plays an essential share in the com-
parative analgesia as it is observed by the surgeon?”
“The Experimental Facts.-Methods of Examination.—Experi-
ments were carried out on dogs, cats, and rabbits, the greater number
on dogs, of which we used more than 60, and our report will consist
principally of the findings in these animals. In the greater number
of our examinations the animals were etherized, the abdominal cavity
in the linea alba opened, and immediately closed with temporary
ligatures held together with clamps. The laparotomy was carried
out step by step; as the incision was lengthened, the wound was closed.
In this manner it was possible to carry the incision almost the entire
length of the abdomen without permitting the intestines to protrude,
and we were especially careful to touch them as little as possible.
“Before beginning the essential part of the experiment the animal
was permitted to come more or less out of the influence of the ether.
In some cases the laparotomy was done under local anesthesia with
cocain, beta-eucain, or tropococain; again, in other cases the laparot-
omy was performed by infiltration of the skin with o.9 per cent, salt
solution. As reactions of the animals, such decided irritation was
necessary as would produce distinct symptoms of active pain, such
as crying out, whining, pulling or actual movements of the body,
sudden wagging of the tail, when the onset or commencement of these
symptoms began abruptly, commencing with the beginning of the
THE ABDOMEN 3I3
irritation and stopping with its cessation. The pulling or turning
of the body and the quick wagging of the tail were accepted as suffi-
cient symptoms of pain where whining, etc., were prevented by
tracheotomy. Rapidity of respiration or stretching of the abdominal
muscles without the other symptoms of pain were considered as reflex
symptoms, which possibly were not accompanied by pain.
“The ether naturally prevented painful sensation. Reactions
which we encountered in experiments before the animal was com-
pletely awake from the ether do not represent as much relatively
as those which occurred in a normal condition. However, it ap-
peared sometimes desirable, especially in restless animals, to apply
the irritation while the animal was still moderately under the in-
fluence of the anesthetic; at these times it was rather a qualitative than
a quantitative test. The contrast from the repose of the animal was so
distinct before the irritation was applied as to leave no doubt, and bore
a direct relation between cause and effect. -
“On the other hand, it appeared without a doubt in restless, con-
tinually whining animals that the irritation caused pain, as all symp-
toms of pain increased so suddenly after the application of the irrita-
tion. Especially after some experience with these kind of experiments
one seldom remained in doubt as to whether a definite reaction caused
pain or not. We may, however, add that we drew our conclusions
from such reactions that left no doubt and, for the most part, after the
agreement of two or more independent observations.
“We, therefore, lay especial emphasis upon this point, as one or
the other observer, possibly after several earlier examinations, may
have become confused or disgusted; and, indeed, in view of the pos-
sible difficulties, to doubt the reaction at times when the animal was
of an especially restless character.
“We will further state that the irritation as well as the reaction
which was produced was only of short duration, and the animal
evidently suffered very little under it.
“We examined along with the intestines also the stomach, liver,
spleen, omentum, mesentery, and kidney. In the greater number of
our experiments we confined ourselves to the intestines, and used
mechanical, electric, and thermic irritation.
“Mechanical irritation consisted for the most part in pressing
the intestines either between the fingers or between the blades of
surgical forceps. Sometimes the intestines were irritated by inci-
sions or by sticking with a needle. For electric irritation we used the
faradic current, and for heat, a test-tube filled with hot water.
3I4 LOCAL ANESTHESIA
“The intestine was tested for sensibility, either within the cavity
or after it had been delivered outside. In the latter cases all or a greater
part of the ligatures were opened, and a more or less larger part of the
intestine brought forward and kept covered by towels wet in warm
salt solution, or only a single ligature was loosened and a short loop
of intestine brought forward; in these cases the delivery of the in-
testine was aided by a silk thread, lightly drawn around the bowels
at the time of laparotomy, the ends knotted and retained outside.
The single intestinal loop was either immediately replaced in the cav-
ity after the irritation or allowed to remain outside and kept moist
and warm with towels. Organs like the liver, kidney, etc., which
could either not be delivered at all or only by pulling upon their
mesentery, were tested within the cavity.
“In numerous experiments the intestines were tested only within
the cavity, and then after the following special method: During
the laparotomy the intestine was loosely fixed between the blades
of an artery forceps covered with soft rubber, and allowed to remain
in the cavity with the handles projecting through the incision. Thus,
pressure on the handles of the forceps outside of the cavity was trans-
mitted to the loop of bowel lying between the blades on the inside.
“In experiments in which the laparotomy was done with local
anesthesia we often irritated the intestines with a forceps, which
was passed through a proportionally Small opening immediately after
the incision. Some other details shall be mentioned in the protocol.
“While Lemmaſideſ and other surgeons accept all pain arising in
the peritoneal cavity as coming either from pulling upon the mesen-
tery or through rubbing the parietal peritoneum, we especially em-
phasize that in our experiments on the abdominal contents we par-
ticularly avoided pulling on the mesentery or irritating the parietal
peritoneum. Moreover, after mechanically irritating the intestines,
we often obtained an equally pronounced positive reaction by pulling
on the mesentery or rubbing the parietal peritoneum.”
“Results.-By far the most important part of our problem was
the question from the physiologic standpoint: Are the organs which
are supplied exclusively by sympathetic nerves provided with afferent
fibers for the impression of painful sensation? We were, therefore,
first concerned with this question. To which our answer, in So far as
the abdominal organs are concerned, is decidedly in the affirmative.
In about 60 dogs, on which we experimented, we missed in only a
single case in the entire number a distinct reaction after irritating the
intestines. The probable cause of the analgesia of that one animal
THE ABDOMEN 3I5
we intend to discuss later. Under reactions we understand, as men-
tioned above, the aforementioned symptoms in the animal—symp-
toms manifesting pains. The measure of these reactions was differ-
ent in the Several experiments, and was repeatedly even different
during the course of one and the same experiment. We intend to
return later to the conditions occasioning these variations, but in
each one of our dogs, with the exception of one, there existed a more
or less long period, during the course of the experiment, in which
an irritation of the intestines produced a stronger or weaker un-
mistakable reaction indicating pain. To illustrate this, we may quote
Some experiments from our records:
“Experiment I, dog No. 14, 4 kg. Laparotomy done under ether, the larger part of
the wound was then closed with sutures except a few centimeters at the anterior end.
Through this part a loop of intestine was allowed to protrude. The loop of small intes-
tine was kept covered with absorbent cotton wet in salt solution.
“Operation ended at II: Io A. M. II: 25 the exposed loop was tested. Pressure with
dull forceps produced a decided reaction; pulling on the mesentery or rubbing on the
wound was carefully avoided.
“Faradization produced the same result. During the faradization the intestinal
loop was carefully lifted from the abdominal wall. Application of a glass tube filled with
hot water produced an undoubted reaction, although after a delay of several seconds
another short loop of intestine was brought forward, and the same three tests repeated
with a similar result as before. The intestines were replaced and the wound closed. (The
experiment was later continued under different conditions.)
“Experiment No. 2, young dog, No. 23, 2.8 kg. Laparotomized under ether; wound
closed with sutures. Operation finished at 12: Io A. M.; 12:40 the dog was placed in a sodium
chlorid bath (39° C.). -
“Abdomen opened by loosening the ligatures; the intestine came forward, but all
remained under water. Tested twice; pressure with the fingers and faradization both
caused pain. Reaction undoubted. (During the faradization the intestine was lifted
for several seconds above the surface of the water. Experiment was continued.)
“Experiment 3, dog No 44, 7 kg. Ether. Laparotomy, closed with ligatures.
Femoral artery prepared for measuring the blood-pressure. Finished at Io:45 A. M.;
11:30 wound opened, intestine came forward under the water. Pulse 120, pressure 140.
Cautious pressure on the intestine causes prompt and strong reaction; irritating the skin
caused only little reaction. In these three experiments as well as in many others under
similar conditions in which the animal had recovered from the ether narcosis, and the
intestine was still in fresh, comparatively normal condition. Strong pressure with the
finger or forceps caused unmistakable evidences of pain. The same after faradization
or touching the intestine with hot test-tubes.
“Experiment 4, dog No. 37, 5.3 kg. The abdominal skin in the lower half of the linea
alba for several centimeters was infiltrated with o.9 per cent. Sodium chlorid solution.
Cutting through the abdominal wall at this point caused only slight pain. A loop of in-
testine came forward spontaneously. Careful testing with firm finger pressure caused
undoubted strong reaction.”
In all of our experiments in which only sodium chlorid solution
was used for infiltration we could, without exception, immediately
316 LOCAL ANESTHESIA
after the opening of the abdomen obtain an unmistakable reaction
by pressure upon the intestines. *
“The following protocol serves as an illustration of a series of
experiments in which pressure was made upon the intestines within
the abdominal cavity:
“Experiment 5, young dog, No. 32, 4.3 kg. Ether; abdomen opened in the lower
part of the linea alba; a loop of intestine was lightly fixed between the rubber-covered
blades of a long curved forceps, with the intestinal loop replaced in the abdomen and
wound closed, except for an opening where the handle of the forceps protruded.
“Ether narcosis stopped. Somewhat later, when the animal was still moderately in
the ether narcosis, we pressed together the forcep handles (this pressure naturally squeezed
the loop of intestine lying between the blades in the abdominal cavity); each time it pro-
duced an unmistakable reaction in the still sleeping animal; simply pulling on the forceps,
which produced a pull on the mesentery, produced only little effect. The blades of our
forceps was lightly bent; the point could, therefore, easily be directed against the peri-
toneum within the cavity. In this way rubbing on the parietal peirtoneum produced a
reaction, which was quite moderate in comparison to the effect produced by pressing to-
gether the blades of the forceps.
“With the method which we describe in this experiment we could
always produce a prompt reaction and have demonstrated it by
many different observations.
“In the following experiment we have attempted, in a certain
sense, to imitate a hernia. The experiment is at the same time a good
illustration of the influence of inflammation upon the sensibility of the
intestines:
“Experiment 6, November 8, Io A. M., young dog, No. Io, 4 kg. Ether; abdomen
opened; a loop of small intestine brought forward and sunk in a pouch between the muscle
and skin, fixed in position with a stitch. The pouch was situated in the lower left side of
the abdomen. The rest of the wound was completely closed. November 9, 3 P. M.,
the animal in good condition; the stitch divided, and the intestinal loop brought for-
ward.
“It appeared moderately inflamed, relaxed, and distended with gas; no visible peris-
talsis. Pressure with the fingers produced clearly more pain than would have been pro-
duced by similar pressure on any other part of the normal skin.
“Heat applied to the intestine produced an equally marked reaction as an application
to the skin. Faradization was followed by a marked reaction, which was at least as active
as that following faradization of the skin. -
“We observed at different occasions that a striking hypersen-
sibility occurs, ordinarily in parts of the bowel in which, in the course
of a long-continued examination distinct symptoms of inflammation
develop. A needle stick, simply touching these parts with an in-
strument, or by merely blowing upon them, is sufficient to produce
a marked reaction.
THE ABDOMEN 3I7
“What we have stated here in relation to the existence of pain
in the intestines, including the colon, applies also to the stomach,
and appears to apply equally to the liver, spleen, and kidney, but our
experience on these organs has been very little when compared to our
extensive experience on the intestines.
“Therefore, from our experience with the dog we may state that
the abdominal organs are supplied with nerve-fibers for the transmis-
sion of painful impressions. If the existence of such nerve-fibers appear
to have been proved, if only on a few dogs, and only occasionally dis-
tinct expressions of pain had been indicated, then it is highly improb-
able that in a single individual of the same species such a wide varia-
tion should exist in such a fundamental fact as the occurrence of
definite important nerve-fibers. -
“As already mentioned, the existence of pain, we can say, in all
dogs on which we experimented and submitting all of our experi-
ments was the appearance of painful reaction in no way an occasional
reaction.
“Our experiments have further shown that in inflamed condi-
tions the sensibility of the abdominal organs is much increased.
It was further frequently apparent that the pain produced by direct
irritation of the intestines was more severe than that caused by
pulling upon the mesentery or rubbing the parietal peritoneum.
The last procedure (pulling on the mesentery or rubbing the parietal
peritoneum) cannot be accepted from this standpoint as the only
cause of intra-abdominal pain in the dog, as Lennander and other
authors assume for the human subject.
“While the total of our numerous and manifold experiments does
not permit of any other interpretation than the one given above,
we must admit that the interpretation of Some single experiments is
not a simple problem. It especially appears to us that the manner
of experimentation as it usually was, and still is, carried on by the free
exposure of the abdominal viscera after a large abdominal incision
gives changing and apparently contradictory results.
“The reaction to irritation of the freely exposed intestine was
always non-uniform, according to the conditions, as to whether the
intestines remained uncovered or covered with moist cloths or the
whole animal with the exposed intestines placed in warm saline or
Ringer's solution. At times the reactions were positive or even
violent, at other times doubtful and sometimes decidedly negative.
We will again illustrate this statement through an abbreviated proto-
col:
3.18 LOCAL ANESTHESIA
*..
“First we want to quote the record of an experiment in which
during no stage of the experiment irritation of the intestine seemed
to have produced an undoubted manifestation of pain.
“Experiment 7, dog No. 28, 3.6 kg. Ether; tracheotomy; abdomen appears dis-
tended; laparotomy. Wound provisionally closed with ligatures. About twenty minutes
after stopping the ether the animal was placed in a sodium chlorid bath, maintained at a
temperature of 40° C. The tracheotomy cannula was connected with a rather wide
rubber tube, about 30 cm. long, so that the animal could breathe when the wound in the
neck was under the water-level (the free end of the tube was placed for a few seconds
under the level of the water; the animal would not aspirate the water, but breathed out
vigorously). The ligatures were loosened, and the abdomen opened under the level
of the water; the stomach and intestines gushed out of the cavity, both markedly dis-
tended with gas. The intestines were irritated by pressure and faradization. Both
irritations caused ‘very little pain,’ but a certain degree of sensation existed. Several
minutes later no kind of irritation produced any reaction. This complete analgesia lasted
through the entire continuance of the experiment. Strong sudden irritation (mechani-
cal and electric) produced no reaction either on the outer skin, nose, or lips, etc. The anal-
gesia was complete for the entire body. Respiration regular, about 40 per minute; pulse
weak, between IIo and 120; blood-pressure not measured. Corneal reflex rather good.
The animal remained in the condition of deep apathy for more than an hour, when it was
killed by sinking the end of the tube in the water. No symptoms of asphyxia, convul-
sions, or spasmodic respiration appeared.
“In the experiment the protocol reports only a ‘little pain,’ and
that but for a short time. During a full hour afterward there were
no symptoms whatever of any sensation in the intestines. We, there-
fore, regard this as a negative result. There was at the same time
complete analgesia of the entire body and the animal remained in a
condition of deep apathy.
“When drowned the usual symptoms of asphyxia, such as respi-
ratory convulsions, were lacking. -
“The condition of the animal is recorded in our protocol as ‘shock’;
however, we will not here discuss further the correctness of this
record.
“As already repeatedly mentioned, we met only once such a case
of total intestinal analgesia during the whole number of experiments.
On the other hand, we possess the records of a fair number of experi-
ments in which a passing analgesia appeared once or several times
during the experiment. To illustrate this state we shall quote the
continuation of Experiment No. 1:
“Experiment I (continued), dog No. 14. After determining that the intestines reacted
plainly to pain they were replaced in the abdomen, the wound closed, and abdomen kept
warm. Finished II : 50 A. M.; I2 : Io the animal was quiet, respirations superficial.
Corneal reflex dull. Pulse IIo. Reacted only lightly to mechanical and electric irrita-
THE ABDOMEN 3I9
tion of the skin. Wound then uncovered, and a loop of intestine pressed out between
the ligatures and allowed to lie outside.
“This loop was distended, cyanotic, and gave scarcely any reaction to irritation; it
was replaced in the cavity and the ligatures tightened. The dog remained completely
quiet. I : Io P. M., dog begins to move; I : 4o, ligatures at the lower end of the wound
loosened, a loop of intestine comes forward. Pressure with forceps and faradization gives
painful reaction. Soon after the intestinal loop became distended and cyanotic, when
the reaction to pressure, heat, and the electric current gradually became weaker and
finally disappeared. Also irritation of the skin showed scarcely any effect.
“The animal was quiet, pulse IIo, intestines replaced in cavity, and wound closed.
“2 : 22 P. M. Ligatures opened and an intestinal loop brought forward. Irritation
of this loop caused strong reaction. The intestine replaced and wound again closed.
(The experiment was continued with cocain injections.)
“In this experiment it happened twice that the intestine after
coming forward became analgesic, while before a quite long and dis-
tinct reaction to pain had been produced. The sensibility to pain,
however, returned after the intestine had been replaced in the cavity
and allowed to remain there for a while. -
“The sensibility of the gut was not lessened if this was brought
out of the cavity for only a short time. At the same time with the
intestinal analgesia occurred a lessening of the general sensibility
over the entire body. In short, the condition was very similar to
that which we have observed during the entire progress of previous
experiments, only that here the condition was temporary and revers-
ible. It is to be noted, however, that in the previous experiments
almost all the intestine was brought out of the cavity and not re-
placed.
“Experiment 8, dog No. 20, 5.2 kg. Ether (it required very much to anesthetize
the animal); laparotomy; incisions closed with ligatures. Narcosis and operation finished
at II A. M.; II: 15, the animal awake, moving, and squeezes a loop of intestine out between
the ligatures. Immediate reposition of the loop causes strong reaction of pain of short
duration, after which the animal immediately became quiet.
“He lay without making a sound or moving, pulse small and very rapid. After some
minutes the pulse again became normal, the animal continuing quiet.
“II : 3o A. M. A loop of intestine was carefully drawn forward. Pressure produced
a positive reaction. The reaction is so active that the animal gets his head out of the
halter, the ligatures stretched, and the abdominal contents were forced out. Scarcely
had the head been secured again when the animal became quiet; irritation of the intes-
tine with strong pressure and with faradization remained negative; no reaction was pro-
duced. The intestines were now covered with wet towels, with the exception of a loop,
which remained uncovered and was not moistened.
“12 M. Intestine (the covered portion) shows no reaction to pressure. Faradiza-
tion, however, is followed by a mild but certain reaction. The skin was also tested for
confirmation; it was negative for pressure, but positive for faradization. 12 : o2 P. M. The
uncovered and dry loop of intestine appeared hyperemic. Pressure gave positive reaction;
faradization by weak currents was positive. 12 : Io P. M. Faradization of the intestines;
32O LOCAL ANESTHESIA
reaction doubtful; equally strong faradization of the skin showed active reaction. 12 : 25
P. M. Pressure on the covered and uncovered portion shows positive reaction; even a
needle stick shows positive reaction. -
“I 2 : 30 P. M. Pressure, needle stick, and hot test-tubes show distinct reaction.
12 : 45 P. M. Pressure, positive reaction faradization even with very weak currents shows
pronounced reaction. No proportional difference between the covered and uncovered
portions of the intestine.
*
“Also in the experiment the sudden delivery of a large part of
the intestine caused temporary analgesia, accompanied by an unmis-
takable depression of the cutaneous sensibility.
“The sensibility of the intestine, as well as the skin, returned after
the intestines had been covered, warmed, and moistened.
“The sensibility not only returned, but seemed so much increased
that even a needle stick caused pain.
“Experiment 9, dog No. 27 (weight not noted). Ether; laparotomy. Around a loop
of intestine a silk thread was drawn, abdomen closed, narcosis and operation finished at
II A. M. II : 25 A. M. The loop of intestine on the thread cautiously drawn forward;
positive reaction to pressure; intestine replaced; some minutes after all the intestines were
brought forward; soon thereafter pressure and faradization were without effect. Fara-
dization of the ears showed little reaction.
“II : 45 A. M. Intestines replaced and abdomen closed; II : 55 A. M., faradization of
ears, positive reaction; I2 : 55 P.M., a loop again drawn forward. Pressure shows posi-
tive reaction. All ligatures were quickly opened and the stomach, intestines, and spleen
brought forward, remaining uncovered and not moistened. For two minutes the intes-
tine remained sensitive to pressure; after that there was a negative reaction to pressure
and faradization, later even very strong faradization is negative. Gradually, the parietal
peritoneum and mesentery completely lose their sensibility. The previously much-dis-
turbed animal had become quict; I : 15 P. M., all Gigails replaced, abdomen ciosed; I : 4o
P. M., a single loop of intestines brought forward; faradization caused very strong reaction.
The intestine replaced; I : 55 P.M., again all ligatures were opened, immediate faradiza-
tion of the intestine gave a distinct reaction; soon after stronger faradization is without
effect. Pupils wide, corneal reflex present, and faradization of the ears gives positive
reaction. -
“Also in the examination was the sensibility of the intestine
abolished, through the delivery of all or a greater part of their length,
and appeared again after replacing them in the cavity and closing
the wound. This was done three times during the same examina-
tion. After each delivery of the bowel the dog was quiet and apathetic;
the skin, however, did not lose much of its sensibility. The delivery
of a single loop of intestine did not lessen the sensibility.
*
“Experiment Io, dog No. 38, 5.1 kg. The skin of the abdomen in the middle line was
infiltrated with salt solution, the abdominal wall for 2 cm. was opened; till now very little
sensibility. Seizing a loop of intestine with forceps was answered by an unmistakable
reaction. Pulling on the mesentery and touching the parietal peritoneum was care-
THE ABDOMEN 32I
fully avoided. Ether narcosis begun; both femoral arteries were prepared for measuring
the blood-pressure. Abdominal incision increased about 20 cm.; a loop of intestine was
lightly fixed between the blades of a forceps. Abdomen closed about 11 : 15 A. M. The
animal is awake, but quiet, lid reflex present. I2 : 25 and I2 : 40 P.M., light pressure with
the forceps causes immediate distinct reaction.; I : oo P. M., blood-pressure wavers around
140 mm. mercury. After opening the entire wound all the intestines were brought
forward. Pressure on the forceps at first causes a quick reaction, but later no response at
all. Blood-pressure at first increased; the arrow, however, soon fell back and remained
around 140 mm. The intestines were soon covered with warm sodii chlor. compresses.
Lid reflex normal, respiration slow and regular, the animal was remarkable quiet. I : 55
P. M., pressure on intestines, active reaction; 2 : Io P. M., reaction to pressure still active.
“Intestines replaced in the abdomen and after some minutes again brought forward.
The sensibility of the intestines disappeared almost completely and the animal was again
strikingly apathetic.
“Blood-pressure remained in the same tube about 140 mm.; 2 : 50 P.M., strong press-
ure on the intestines (which had remained out) produced again a little reaction.
“A noteworthy observation in this experiment is the fact that
the lessening of the sensibility of the intestines and the apathetic
condition of the animal was in no way accompanied by a fall in blood-
pressure.
&
“Experiment II, dog No. 39, 9 kg. After infiltration with salt solution a small inci-
sion was made, and the sensibility of the intestines within the cavity was tested. Reaction
distinctly positive. Etherization. The animal slowly entered narcosis. Both femoral
arteries prepared for measuring the blood-pressure, abdomen widely opened, and a loop
of intestine fastened between the blades of the forceps. Abdomen closed and ether stopped
about Io :55 A. M.
“From II : 15 to II : 35 A. M. the animal remained completely quiet. Light pressure
on the forceps produced a distinct reaction, which was tested several times with similar
result; II : 4o A. M. all ligatures quickly loosened, the intestines gushed out; now light
pressure on the forceps on the same part of the bowel produced no reaction, stronger
pressure producing only little expression of pain.
“The animal begins to be excited, moving quickly, respiration slow, pulse rapid, blood-
pressure about 140 mm. The sensibility of the intestines soon began to return again,
slowly but surely. The intestines remained covered with Salt solution compresses.
“I 2 : 3o P. M., the intestines were manipulated in different ways. The sensibility
was distinctly lessened by these manipulations, but soon returned. The examination
was repeated four times with similar results. The sensibility was each time apparently
diminished, but did not completely disappear, and soon returned to its original intensity.
Blood-pressure remained about 140 mm. I : Io P. M., sensibility pronounced, even
light pressure producing an active reaction. After replacing intestines and repeating the
eventration, the sensibility almost completely disappeared; blood-pressure remained
about the same.
“From this experiment it is evident, aside from the repetition of facts from former
experiments, that the reposition of the intestines in the abdominal cavity and their manip-
ulation produce a reduction of the sensibility, but this reduction was not so great as
in former experiments and not so lasting.
“The animal was by nature very sensitive and reacted to ether extraordinarily. Dur-
ing the variations in the sensibility in this experiment there was no corresponding varia-
tion in the blood-pressure.
21
322 LOCAL ANESTHESIA
“The contrast between the sensibility and the variability of the
blood-pressure was clearly shown in many of our experiments. Espe-
cially striking was this in the cases where the animal was kept in a
warm bath of Salt solution or Ringer's solution. The blood-pressure
remained moderately high while the animal was apathetic, and the
intestines and skin either lessened or lost their sensibility. In some
cases, however, the blood-pressure began finally to fall, and the
animal passed into a condition of true shock. Similar experiments
were also conducted on cats and rabbits, but the results were unsatis-
factory, as it was often difficult to tell when these animals suffered.
They were further very easily affected by laparotomy, showing pro-
nounced depression and inhibition early in the course of the experi-
ment.”
“Review of the Facts.--When the sensibility was tested within
the closed abdominal cavity with the help of a forceps, after the ani-
mal had completely or partially come out of the anesthetic, moderate
pressure caused each time an unmistakable—at the same time active—
reaction. We met in this relation no single exception. If the abdo-
men was opened through the analgesic action of local infiltration, and
immediately moderate pressure made upon an intestine loop by means
of a forceps introduced into the cavity, it showed in each case a dis-
tinct unmistakable reaction without a single exception. In these, as
in other cases, was especial care exercised to avoid pulling on the
mesentery or rubbing the parietal peritoneum. Moreover, in these
cases was it frequently observed that pulling on the mesentery or
rubbing the parietal peritoneum caused less pain than pressure upon
the intestine.
“When a small loop of intestine was carefully drawn out of the
cavity by means of a thread and pressure made upon it, we were each
time able to demonstrate a positive painful reaction, but this, as a
rule, was always less than when the intestine was tested within the
cavity. On the other hand, there was not a single case in which the
sensibility was not absent for a longer or shorter time, or at least
materially lessened if the entire abdominal contents or a large part
of them were drawn out of the cavity through a large incision. As a
rule, the diminution of sensibility began after two or three minutes
free exposure. At the same time with the depression of the intestinal
sensibility the animal developed a general apathy. The restlessness
and movements of the animal, noticeable before the cavity was widely
opened, ceased suddenly, and the animal sank into a condition of deep
apathy after the symptoms incident to the evisceration had ceased.
THE ABDOMEN 323
The animal lay without making a sound, with wide open eyes and more
or less prompt lid reflex. This condition was frequently accom-
panied by a more or less pronounced depression of the cutaneous sen-
sibility. As a rule the blood-pressure first rose, but soon fell back
to its original point; it was never less than before the delivery of the
intestines, providing that their exposure and the condition of apathy
was not continued too long. The respiration was frequently rather
slow and sometimes of a Cheyne-Stokes type. The pulse was often
rapid, yet only temporarily; it would soon slow down and remain at
the normal frequency. When the eventration was quickly done the
loss of sensibility of the intestines was clearly marked, yet even when
slowly and gradually done a distinct loss of sensibility always followed;
if the eventration itself clearly caused pain or it was produced through
quickly replacing the organs in the cavity, this loss of sensibility both
within and out of the cavity was hastened and seemed to be more
pronounced. On the other hand, evisceration seemed to reduce the
sensibility much less if ether had been given for a short time.
“It was manifested that the general condition of the animal played
an influence in the development of this condition of loss of sensi-
bility. In strong, sound, lusty animals, as well as in those which in
general reacted quickly to irritation, this loss of sensibility appeared
less quickly, was less marked, and disappeared quicker than in weak
dogs. The duration of this condition lasted longest if the animal
was placed in a warm salt bath, and lasted perhaps still longer if a
bath of Ringer's solution was used; often, however, the sensibility did
not return and the animal passed into a condition of veritable shock,
with rapid pulse and falling blood-pressure. But this condition
during the relatively short duration of our experiment never led to
the death of the animal; each one had to be specially killed.
“If the animal was not placed in a water bath, and the intestines
were exposed to moist or dry air, the sensibility of the intestines re-
turned sooner or later, though only rarely, to the original degree,
except those parts which clearly showed inflammation. On these
the sensibility frequently exceeded the sensibility of the normal
conditions. The return of the sensibility was completed when all
the intestines were returned to the abdominal cavity, the wound
closed, and the animal covered and a sufficiently long period of rest
allowed. If after this a single loop was withdrawn for testing, it was
frequently found to have returned to the normal degree of sensibility.
“As a rule, the animal did not recover from the general condition
of apathy before the return of the intestinal sensibility. As long as
324 LOCAL ANESTHESIA
the intestines remained out of the cavity and appeared insensible to
irritation the condition of general apathy continued. After the repo-
sition of the intestines and closure of the abdominal cavity the animal
usually remained completely quiet for a while, but later became
restless and began to whine. If now a short loop of intestine was
tested, it showed that the sensibility had already returned.
“In certain cases when, for example, a part of the intestines was
inflamed, it appeared to be even hyperesthetic, although the animal in
general still appeared indifferent. But here there existed an appar-
ent difference between strong naturally sensitive animals and weak
quiet ones. The former showed less deep apathy, and came out of
this state earlier than the latter.
“These are, in general, the facts from which we arrived at the con-
clusions from our experiments. It can briefly be stated that the
abdominal organs of the dog, without exception, are distinctly sensi-
tive to pain as long as they remain in the closed abdomen. Extensive
laparotomy, on the other hand, a free exposure of the abdominal
organs influence to a high degree their sensibility, frequently to such a
degree as to lose all sensibility, and this either temporarily or perma-
nently.” -
“Old Experiences in a New Light.—In the last-named condition
is no doubt to be found an explanation of the contradictions in the
statements of earlier investigators. In the field of the sensibility of
the abdominal organs almost all investigations were carried out after
free opening of the abdominal cavity, thereby depriving the Señsitive
intestines of the protection which the closed abdomen afforded. The
results could, therefore, differ according to different conditions.
“They may be differently manifested according to the individual
differences in the sensitiveness and state of health of the animal; ac-
cording to the time after the incision in which the observation was
made, or according to the treatment to which the free exposed organs
have been subjected; the variations may yet correspond to many other
factors. We take, for example, one of our experiments in which the
intestines were brought forward, and we can easily understand how
three or four different observers, who would make examinations in
the different states, would arrive at different conclusions. One
observer would perhaps examine them immediately after their delivery
and would find pronounced sensibility; the other would decide to
wait until the animal was quiet,’ and is then not in a condition to be
sensitive. The third would wait perhaps somewhat longer before
testing the sensibility, and would then confirm the return of sensibility
THE ABDOMEN $ 325
to a moderate degree. And still somewhat later, after a part of the
intestine had been sufficiently exposed to have become clearly inflamed,
a fourth observer would find a condition of hypersensibility.
“Inhibition of the Sensibility Produced by Laparotomy.—The
lessening or complete loss of sensibility can occur either through a
depression of the power of perception of the peripheral endings of
afferent nerves in the abdominal organs or through inhibition of their
central endings. In other words, the inhibitory effect can either be
of a peripheral or central nature, when, after the loss of intestinal
Sensation, there is a more or less marked depression of the cutaneous
sensibility, it is evident that at least in this way laparotomy may
exercise a central inhibitory influence. It is, therefore, very prob-
able that the loss of intestinal sensibility is essentially of central origin.
“In conclusion, we can therefore say that extensive opening of
the abdominal cavity, manipulation of the intestines, eventration,
etc., exercises a profound inhibitory influence on the motor and sensory
mechanism of the intestinal tract, whereby the wave of inhibition
spreads within the central nervous system to other sensitive and sen-
sory mechanisms.”
“General Information.—Along with the statement that the
abdominal organs are innervated with sensory fibers, the above state-
ments also convey other information which is of general significance.
For examinations of processes in organs that are lying in serous
cavities in surgery, as well as in experimental physiology, the simplest
method seems to be to open the cavity and thus directly to inspect the
organ. The above-mentioned facts teach, on the contrary, that the
opening as such considerably influences the motility as well as the
sensory process, and what one sees are not the normal but the con-
siderably altered conditions of the internal organs. For the inves-
tigation of a noise in a closed room it is not always the best method to
look for the cause through the open door; the opening of the door
often will suddenly stop the noise; here, as well as in biology, one often
arrives at the best result by observing the process through the key-
hole.
“Before we conclude this part, we will again especially empha-
size, that the general condition of the animal is an essential factor
in influencing the sensibility through laparotomy. The weaker the
animal the greater the influence, so that in quite depressed animals
the simple opening of the abdomen not only leads to a pronounced
depression of the sensibility of the abdominal organs, but may even be
followed by veritable shock.” -
326 LOCAL ANESTHESIA
“Conclusions.—The abdominal organs of the dog, examined
through a small opening in the otherwise closed abdominal cavity,
are undoubtedly sensitive to pain, and are also sensitive outside of
the cavity, if only a small loop is brought out and tested immediately
after its exposure. Inflammation undoubtedly increases the sensi-
tiveness of the abdominal organs of the dog. If all the intestines or
a greater part are eventrated or otherwise freely exposed, there ap-
pears a more or less marked depression of the Sensibility, which is
more complete the weaker the animal is; at the same time the animal
becomes more or less markedly apathetic with lessening of the cu-
taneous sensibility. Laparotomy also depresses the motor activity
of the gastro-intestinal canal. This motor and sensory depression is
a reflex inhibition of central nature, and can also extend to other
CenterS.
“In weak animals and in prolonged procedures this inhibition may
extend to the vital centers in the medulla oblongata, and may often
lead to fatal shock. -
“It also appears that the peripheral mechanism in the intestinal
canal may also be inhibited to a certain degree. It is evident, also,
that the intestines of cats and rabbits possess sensory nerves, but they
are easily exhausted and are very early and strongly influenced by
laparotomy; the intestines are affected much quicker and more pro-
foundly than the mesentery. The surgical experience on the human
Subject does not at all prove that the intestines normally in the
normal closed abdomen possess no pain-conducting fibers. Until
exact proofs are brought forward that the sensory innervation of the
human abdominal organs differs radically from that of other animals
it will have to be assumed that as with animals, so also with man,
the abdominal organs are provided with special nerve-fibers, and that
the Sensation of these organs can be increased by inflammation as we
See it in animals.
“This theory explains in a simple way the well-known occurrence
of all kinds of violent pain in the human abdomen.”
After reading the preceding, one is almost forced to conviction of
these views were it not for the daily repeated observations at the
operating-table upon the human subject, when it becomes self-evident
that they cannot be unreservedly accepted for the human body with-
out further observations, and we realize that on this perplexing sub-
ject the last word has not yet been spoken.
It is very probable that in the highly organized human body condi-
tions of sensibility differ from those found to exist in the animal in
THE ABDOMEN 327
accordance with the well-known law that the higher we ascend in
the animal Scale the more highly organized, complex, and sensitive
becomes the nervous system. The fact that moderate doses of cocain,
I to 3 cg., is sufficient to abolish all intra-abdominal sensation in
dogs, and that large doses are capable of producing general anes-
thesia in man, must be taken into consideration in arriving at any
conclusions regarding intra-abdominal sensations during operations
upon man under local anesthesia, where it is also possible that the
acuteness of the Sensibility of these parts may be somewhat lessened;
also the fact, demonstrated by Kast and Meltzer, that free exposure
of the abdominal contents inhibits or completely abolishes all local
as well as general sensibility; the fact that such exposure if prolonged
leads to shock has been recognized in man, but observations on the
Sensibility, either local or general, long before shock appeared had
not been reported; it is, however, well known that during shock all
painful sensations are either greatly lessened or entirely abolished.
The “apathetic state” reported by Kast and Meltzer, even without
any fall of blood-pressure, must be recognized as a condition which
immediately precedes shock, as indicated by the blood-pressure.
The question of the lessened intra-abdominal sensibility through
the use of cocain or its substitutes, and the depression of sensibility
through exposure of the abdominal organs in man, must now remain
an open question until proved by further observation on the human
subject made with this end in view.
In considering some of the above questions in the light of infor-
mation already obtained from operations performed on man, it has
been proved that the existence of adhesions between movable intes-
tinal coils does not excite pain as a symptom; other disturbances may
arise, but when adhesions have existed between the intestine and the
abdominal wall pain has always been complained of. In operating
upon such cases under local anesthesia, the separation of the adhesions
between the several loops of intestines, no noteworthy complaint is
made by the patient provided the mesentery is not pulled upon, but
in separating adhesion between the intestines and the abdominal wall
pain is always complained of.
If a finger is introduced into the abdominal cavity and firm
pressure made against the parietal peritoneum no pain is produced,
as the parietal peritoneum is insensitive to pressure, but by sliding
the finger about over the surface, traction is made on the delicate
and sensitive subperitoneal tissue and pain produced. In this way
Lennander believes that the pain of some forms of colic not explained
328 LOCAL ANESTHESIA
by pulling on the mesentery may be accounted for. The gradual and
general distention occurring in ascites, large tumors, pregnancy,
etc., may not cause pain, but the unequal distention and violent peris-
talsis of a small loop may, by a sliding motion on the parietal perito-
neum, excite acute pain.
The withdrawal of packs and drainage-tubes from between coils
of intestines excites very little pain, provided the mesentery is not
pulled on, in comparison to the pain produced by removing them
when in contact with the abdominal wall. In operations under local
anesthesia the careful, gentle application of packs around the field
and in contact with the parietal peritoneum does not excite any com-
plaint, but when being removed if they are roughly dragged out the
patient will always give unmistakable evidence of decided pain.
Investigations under similar conditions to those employed by
Kast and Meltzer have been undertaken by Müller, but he did not
obtain the same results; also by Hotz, but here the observations were
made under morphin narcosis, and are, consequently, not of the same
value; however, he states that irritations of violent kinds, even in in-
flamed conditions, do not excite pain unless the mesentery is pulled upon.
Ritter, on the other hand, tried similar experiments, and was able
to completely confirm Kast's and Meltzer's findings and oppose those
of Lennander. In 1909 he brought forth an entirely new theory. He
believes that the sympathetic nerves are capable of the transmission
of painful impressions, but associates such sensation directly with
the blood-supply, and found that the more vascular parts were the
more sensitive, the non-vascular, less so; the vessels themselves are
most sensitive, and in every instance were painful when ligated. He
thinks that this means of testing the sensibility of these parts is the
only one that eliminates all possibility of error. Pulling upon the
mesentery was eliminated by a series of double ligatures; in placing
these, if the proximal was tied first it alone caused pain, the applica-
tion of the distal one being painless; but if the distal one was tied
first, then both caused pain. He found that cocain injected around
the blood-vessels renders anesthetic the viscera supplied by them, and
thinks that injury to the vessels is important in the production of
shock, and advises that when working under local anesthesia all ves-
sels of any size should be cocainized before ligation and division.
He does not think that the cocain used in performing laparot-
omy has had so much to do with the negative findings of many sur-
geons as the inhibition of sensation brought about by the exposure
of the delicate nerve-fibers in the abdominal cavity.
THE ABDOMEN 329
These later findings by Ritter have attracted the favorable at-
tention of some observers; further investigations may prove their
value, but we must bear in mind two points: first, that cutting off
the blood-supply always lessens the sensibility of the parts; second,
that the sympathetic nerves (if they have been proved to contain pain-
conducting fibers) are largely distributed upon the blood-vessels, and
the ligation of these vessels may completely block their power of
conduction.
In another publication Ritter has stated that the free exposure
of the intestines in non-anesthetized patients, as well as pinching them
with forceps, causes pain. Mitchell reports 2 cases and Haim I case
operated without narcosis and without cocain, and they state that the
lack of sensibility of the intestines was similar to that observed in
similar operations under cocain. Two of these cases had carcinoma of
the stomach and the third an irreducible hernia. While these ex-
aminations were more to the point, the cases must have been very ill
to have been operated without any form of anesthesia, and this condi-
tion must have had some effect in shocking or inhibiting the sensi-
bility; however, the number is too small from which to draw any
definite conclusions. Nystroem, a former assistant of Lennander, in
a recent paper champions the theories of his former chief, and ques-
tions the value of experimentation upon animals in settling these
points, and calls attention to the widely different results obtained by
different investigators in the same experiment. He tried the same
experiments carried on by Kast and Meltzer, and obtained exactly
opposite results, and could excite no pain unless the mesentery was
pulled upon or the parietal peritoneum irritated. He then experi-
mented upon a case of hernia in a man: the abdomen was first opened
by a small incision under ether narcosis, the peritoneum was then tem-
porarily closed, and the patient allowed to recover. The parietal
peritoneum was then tested and found very sensitive, but the irri-
tation of a loop of intestine which was found presenting at the open-
ing gave no evidence of sensation until the mesentery was pulled
upon. From these and other observations Nystroem concludes that
the contradiction of Lennander’s work is not to be unhesitatingly
accepted. While he admits the existence of many points which can-
not be satisfactorily explained by these views at present, it is wise to
withhold judgment until further observations can be made.
Kast and Meltzer, in discussing the opposing views given by some
of the above-mentioned investigators, state the following:
“Now we will try to solve the question on the ground of our ex-
33O LOCAL ANESTHESIA
perimental experiences. In dogs we have almost, without excep-
tion, confirmed the sensibility of the abdominal organs; we have
found that by the free exposure of the intestines their sensibility is
reduced and that this reduction is more pronounced the weaker the
operated animal. We have further found that in cats and rabbits the
abdominal contents are Sensitive, but that in these animals the open-
ing of the abdomen exercises a much stronger influence upon the sen-
sibility than with dogs, and that often a single exposure and irritation
suffices to suspend reaction. The sensibility of the intestines is yet
more fleeting than that of the mesentery, and with rabbits more fleet-
ing than with cats. How does it stand now with the sensibility of the
abdominal organs of man? Here we have essentially the principal
question in view: Do the abdominal organs of man possess pain-
conducting fibers?
“This has been positively denied by competent surgeons. If one,
however, considers how such a denial involves theoretically and
practically very important assumptions, and if one considers still
further how such an assumption must now appear even more import-
ant, since it establishes a radical difference in the innervation between
man and other mammals, it is, therefore, clear that such a state-
ment can only be accepted when based on exact proofs. But are
there such exact proofs? We have first the large number of observa-
tions which have been made under cocain anesthesia, but we have
proved that a cocain injection, even without touching the intestine,
is able to temporarily abolish this sensibility. The surgeons who have
not sufficiently investigated it doubt this statement. But it is a
certain fact, and it has also, as above mentioned, been recently con-
firmed by Ritter. Here one must consider that to reply to our ques-
tion in the affirmative it is not at all necessary to assume that the
sensibility must be intense.
“It may appear in man after opening the abdomen as weak as we
have found it in cats and rabbits, and the Small doses of cocain which
are ordinarily used may, therefore, completely suffice to suspend this
slight sensibility. Also the surgical observations which have been
made with the use of cocain are absolutely not such convincing proofs.
May the few recent observations which have been made without
the use of cocain in these cases be accepted as such positive proof?
Certainly not. Again, have we seen that other observations speak
for the contrary that the human intestines have painful sensations.
We must further mention that the above-cited three negative obser-
vations were made upon very sick patients, and here we must remem-
THE ABDOMEN 33 I
ber our experimental experiences that the weaker the animal the more
profoundly was the Sensibility reduced by laparotomy; and yet, again,
may we add that as regards the sensibility of the abdominal organs
of man after laparotomy they may behave as in cats and rabbits.
“To recapitulate, the observations which were made under the
use of cocain are on account of the cocain not of proportionate value.
The observations which were made without cocain are quite small in
number, are not without contradiction, and were made on very weak
patients. Moreover, laparotomy depresses the sensibility consider-
ably, and in quite weakened animals, also in several kinds of animals
in rather normal condition, was the sensibility completely suspended.
The surgical observations contain, therefore, not only no kind of
positive proof, but contain in general no proof at all that the abdomi-
nal organs of the normal man in the normal closed abdomen are unable
to feel painful sensations.
“As we have no proof to offer, we are justified in accepting that
the visceral innervation of normal man in the normal closed abdo-
men does not differ essentially from that of other mammals, and that
the abdominal organs are more or less richly provided with pain-
conducting nerve-fibers. We are further justified in accepting that
as with animals, so also with man, a marked inflammation strongly
increases the sensibility.
“Based on the above assumptions, the most widely different in-
tense pain that the human in his normal closed abdomen often has
to bear find their simple explanation, and do not need any interpreta-
tion by forced hypothesis.”
Investigations have been undertaken with a view of determining
the sensibility of the mucous membrane at various points along the
alimentary canal, and, while the results of these investigations agree
on nearly all points, there are still some dissenting opinions. These
tests were made through gastric and intestinal fistula or artificial
ani, or by passing instruments into the stomach through a stomach-
tube, or into the rectum through a speculum; the results of these
examinations have been that the mucous membrane of these parts
has no sense of touch, pain, heat, or cold. In 1909 Zimmerman
published the results of an extensive series of experiments upon him-
self and on patients. These experiments were principally upon the
stomach and rectum, and were performed without any anesthesia;
the mucous membrane of these parts was irritated in a variety of
ways—by pinching with forceps, by electrodes, and by the cautery.
In the stomach there was no response to any form of irritation, but
332 LOCAL ANESTHESIA
decided pressure gave rise to a sense of fulness. In the rectum, 6 cm.
above the external sphincter, there was no sense of any kind except
for pressure and differences in pressure could be noted.
The esophagus was Sensitive to both heat, cold, and pressure.
Regarding these experiments upon the rectum, the author has tested
the sensibility of the rectal mucosa and found that above the anal
canal there is practically no sense of pain to Superficial irritation,
and the mucous membrane can be cut and cauterized without any
complaint. On one occasion a polypus was removed by cutting, with
cauterization of its attachments, with an electrode without any
complaint from the patient, although this region felt sore for several
days afterward. Schwenkenbecker in 1908 described his sensa-
tions after taking large doses of menthol, which produced on the
sensitive mucous membrane of the mouth an intense feeling somewhat
between burning and cold. After the drug had passed the level of
the larynx there was no sensation until the anal canal was reached,
when the feeling of cold was again produced. He concludes from this
observation that the mucous membrane of the alimentary canal is
insensitive except at its upper and lower ends.
We know that certain affections of the stomach, notably ulcer,
give rise to pain, although they may exist for long periods of time
without the patient's knowledge, and intestinal ulcers may go on to
perforation without the patient having been aware of their existence;
similarly, the ulcers of typhoid fever seem to excite no pain. Len-
Haſider maintains that a gastric ulcer excites no pain unless accom-
panied by a lymphangitis, and that hyperacidity excites pain when
the irritating or chemical substances are carried by the lymphatics
to the sensitive abdominal wall (posteriorly). Mueller, in discussing
this point, admits that the stomach shows no reaction to touch, cold,
or heat, as far as external stimulation is concerned, but asserts that
it does react to certain internal irritations. He believes that the ab-
dominal organs do possess certain sensations necessary for protec-
tion from toxic or chemically irritating substances, and are capable
of mechanical irritation by overdistention. The sensations thus
produced he attributes to the sympathetic nerves, which, under or-
dinary normal conditions, do not transmit painful impressions, but
become capable of feeling pain under the irritation of abnormal or dis-
eased conditions. When all the evidence, pro and con, regarding the
sensibility of the abdominal organs has been gathered and carefully
sifted down, we have to admit that the crucial test must be the appli-
cation of these findings by the practical Surgeon at the operating-table
THE ABDOMEN 333
upon the human subject, and here, so far, Lennander's views have
largely been substantiated. In the experience of the writer the intes-
tines are devoid of Sensation unless the mesentery is pulled upon;
after extensive manipulations the patient may complain of a peculiar
visceral Sense, hardly a pain, but at times sufficient to excite some
complaint. We have frequently explored limited parts of the ab-
dominal cavity by introduction of the fingers or hand, and when care-
fully done, avoiding friction on the parietal peritoneum, it caused no
complaint, except in the region of the foramen of Winslow over the
Celiac plexus; here the parts seem particularly sensitive. The parietal
peritoneum and mesentery have always been found sensitive, except
when controlled by the injections of the anesthetic solutions; it is
certain that only those parts controlled by the injections would stand
operation; that the solution used may have had some controlling or
lessening effect upon the sensibility of other parts may be possible,
but we have never observed the general analgesia, such as that re-
ported by Kast and Meltzer upon dogs, when using cocain or any
other local anesthetic agent, and any extension of the incisions to the
recognized sensitive parts, if unanesthetized, has always excited pain
and required additional infiltration. In some few very extensive
intra-abdominal operations undertaken with local anesthesia, where
large quantities of the anesthetic solution were used and large parts
of the intestines and other organs exposed, the prolongation of the
operation, instead of lessening the sensibility, seemed rather to increase
it.
In numerous operations for artificial anus where a loop of bowel,
usually the descending colon, has been fixed outside the abdominal
wall, either under local or general anesthesia, and opened several
days later without any form of anesthesia, I can remember no case
where any complaint was made. This opening was made either with
knife, Scissors, or cautery, and later, after retraction had taken place,
the excess of tissue was trimmed down level with the abdominal wall.
Whether the long exposure and changes occurring on the surface of the
bowel was sufficient to destroy the sensibility of the part or not is
possible, but it is certain that these cases have not, as a rule, re-
quired any form of anesthesia for the opening of the bowel. The
same may be said about the stomach in operations for gastrostomy,
as in the Ssabanajew-Frank operation, where the stomach is opened
a few days later, after adhesions have taken place.
A careful study of the preceding pages should prove particularly
interesting to the practical surgeon who attempts to deal with intra-
334 LOCAL ANESTHESIA
abdominal conditions under local anesthesia. Nowhere better than
in the abdominal cavity is the fact demonstrated that the skilful use
of local anesthesia is in itself an art. What one operator does with ease
seems to another impossible, and he may even discredit the statements
of the other. Here, in addition to a thorough knowledge of technic,
it is absolutely essential to possess an accurate knowledge of the manip-
ulations which cause pain, the parts most susceptible of painful im-
pressions, and the conditions which intensify these impressions, such
as inflammation.
We all agree that certain of the intra-abdominal contents possess
painful sensations; these are especially all blood-vessels except the
smallest divisions (and this rule holds good elsewhere in the body),
and the mesenteries and attachments of the viscera to the abdominal
wall. As the blood-vessels almost invariably lie within the folds
of the mesentery, this limits the areas of sensibility under ordinary
conditions (the absence of inflammation) to the mesentery and the
parietal peritoneum. I have never found that incision, clamping,
or suture of the stomach, large or small intestines, gall-bladder, or
uterus upon which I have operated ever gave pain, providing the sur-
rounding parts were not disturbed by rough manipulations that
would make traction upon the mesentery, and when it was necessary
to include the mesentery in the field of operation, as in resections, a
moderate injection of anesthetic solution between its folds and at
some distance proximal to the field always sufficed to control these
sensations, providing there was no traction.
It is essential for these reasons that rather free incisions be made
to permit the ready manipulation of the parts as much within the
cavity as possible and render unnecessary undue traction and dis-
placement.
We should now, for a thorough understanding of our subject, be
able to account for the pain-conducting nerve-fibers within the cavity.
We know that all the abdominal organs are innervated almost
exclusively by the sympathetic system, and that all the sympathetic
ganglia as they lie against the vertebral column, both within the ab-
domen and above, receive fibers from the spinal nerves just after
emerging from the vertebral foramina (Figs. 73–75). It has been
impossible to trace these nerve-fibers to their ultimate distribution—
most are soon lost in the intermingling of nerve-fibers of that region,
some few have been traced to the mesentery, but could not be followed
further, as it is impossible by any known methods to distinguish
between sensory and other nerve-fibers. As all painful impressions
THE ABDOMEN 335
must come through the cerebrospinal nerves, it is in fibers supplied by
these communicating branches that we must look for the paths of
these sensations.
lesser sºlunthnic nerve ºr * lººphragm x * x
interestat servex: ramus wºmmunicans
- interpstainervexit
ºriº Xix
thoraciº -- - - -
T --- - - - - coeliae art. x
gºneſia
media crus of -Mumbar nerve 1
tumo. Port of
diaphra superior mesenteriº
phragm. T art.--
ºriº-rº z - lumbar
roeliac gangſion -- - --- nerve in
ſtorlinealeru - - º - --Ouadratus
- - -- " ſamborum
abdominataortie
--- alexus
renal
plexus--
ranar
artery &
superior
mesenteria
gangſion
sympatheti
lumbar
-nerve ºr
Quadratus
lumborum -
inferior - - - - Tnerve 1/
mesenteria - - -
alexus
iliar crest-T
trunk
hypogastric -
plexus x - º sarral
nerve iſ
sarral
nerve ºf
ºnnbar
gangſton
ranui
tommuni. --- - - - -
rantes - - - -
- - - - - - - - ---sacral
nerve 111
--_sarral
nervery
snºrmſ
gangſion
arefabulu
- rººms. Tº w * * pudendal. \
tory gear gangſion corrygeal nerve sarº) nerve V plexus sacral plexus
Fig. 75–The abdominal and pelvic portions of the sympathetic trunk. The
anterior abdominal and pelvic walls have been removed, the lumbar plexus exposed by
removal of the psoas major, and the aorta left in situ up to its bifurcation. *=Vis-
ceral branches of the pudendal plexus. (Sobotta and McMurrich.)
An effort has more recently been made to reach these rami com-
municantes, and at the same time block the parent trunk by reaching
these nerves just as they emerge from the vertebral foramina; thus, by















336 LOCAL ANESTHESIA
a paravertebral injection (by one injection) securing both visceral as
well as parietal anesthesia of the entire distribution of the nerve. This
method is spoken of more in detail under this heading.
As a general proposition, it may be said that in operations upon
any intra-abdominal part a thorough infiltration of the abdominal
wall in the line of incision is the first essential feature. Should the
operation be upon the fundus of a part or at Some distance from its
mesenteric attachment, no further anesthesia may be required, but
should the field of operation involve the cervix, hilum, or mesenteric
attachment of the part, these must be thoroughly blocked. These
principles, when properly applied to the various parts, are the essen-
tials of the anesthetizing process.
Braun, in infiltrating the abdominal wall preparatory to its in-
cision, makes the injection around the field in more or less rhombus
shape. This is best illustrated by making an injection around the
middle line—we will say, for an operation upon the stomach. A line
of cutaneous anesthesia is established on each side two or three
fingers-breadth from the middle line; starting on this line at two or
more points, depending upon the extent of the proposed incision, the
long needle is entered and directed obliquely outward, injecting as it is
advanced, piercing the rectus sheath, which is recognized by its slight
resistance to the needle, and advancing some little distance within this
muscle until it is quite freely injected; the needle is then partially
withdrawn, when it is advanced again in two or more directions above
and below, slightly increasing the angle each time, thus making the
injection in something of a fan-like shape; this is done along the line
of cutaneous anesthesia at two or more points, having the fan-like
areas of infiltration come in contact with the one above or below. The
same procedure is repeated on the opposite side. These two lateral
lines of infiltration are joined above and below by subcutaneous in-
filtration, as shown in Fig. 76.
While the above method of Braun is certainly found useful in
thin subjects, in thick abdominal walls heavily overlaid with fat
it is unsatisfactory, takes longer to carry out, and requires some little
delay before the solution has thoroughly diffused in all directions
and anesthesia established. I usually prefer to establish a wall of
anesthesia along the proposed line of incision from the skin to the
peritoneum, and have not found that muscular contractions interfere
if anesthesia has been perfect, and no pain excited either in the
incision or operation on the deeper parts, the muscles usually being
..quite relaxed. The method of procedure is usually as follows: An
THE ABDOMEN 337
intradermal wheal is established midway along the line of the proposed
incision; the long needle with Io c.c. syringe is entered at this point
and directed up and then down, without withdrawing the needle, along
the proposed line of incision in the subcutaneous tissues, injecting
freely as the needle is advanced, detaching and refilling the syringe as
occasion requires; without withdrawing the needle" from the skin
its direction is now changed, and it is passed inward toward the rectal
sheath; this is the first plane of decided resistance which the needle
encounters; this is gently pierced, injecting as the needle is advanced
Fig. 76–1, Braun's method of anesthetizing abdominal wall around area of incision; 2,
author's method: infiltration of line of incision from one midpoint.
to about 1 cm. within the sheath; the needle is then partially with-
drawn and redirected within the sheath at several points above
and below in a similar manner (Fig. 76). Returning now to the
skin, the intradermal infiltration is completed along the proposed line
of incision. The deeper injections thus made first have ample time to
diffuse. Having completed the skin infiltration, the incision is made
down to the rectus sheath without need of further delay; with the
rectal sheath now within plain view, further injections can be made

22
338 LOCAL ANESTHESIA
within it if necessary. At this point the Superficial vessels are ligated,
getting rid of the forceps, and allowing the deeper injections more
time to diffuse during this interval. The rectal sheath is now slit up
and the muscle-fibers separated, exposing the posterior sheath; this
is now penetrated at several points with the needle and freely infil-
trated posteriorly in the retroperitoneal tissue, this last injection freely
diffusing to the peritoneum; the posterior sheath and peritoneum are
now opened.
This method I have found to be highly satisfactory and quickly
executed, and employ it almost invariably for incisions through any
part of the abdominal walls.
The solution usually preferred for these incisions, as well as for all
work within the cavity, is No. 2 (o.5o per cent. novocain in o.o.4
per cent. NaCl), adding about 1o drops of adrenalin to every 3 or 4
ounces of the solution used.
The nerve-supply of the abdominal walls is given in the chapter
on Hernia.
POSSIBLE SCOPE OF OPERATIONS WITHIN THE ABDOMEN
All simple operations, such as gastrostomy, gastrotomy, Colostomy,
appendectomy, and gall-bladder drainage, are quite Satisfactorily
performed on suitable subjects (when not too nervous or apprehensive)
when the parts are fairly easily accessible, and not matted down by
inflammation or adhesions to the parietal peritoneum or surrounding
organs; consequently, only such operations should be undertaken when
it is known beforehand that favorable conditions exist. A fairly
satisfactory exploration can be done under local anesthesia by making
a free incision to permit the easy introduction of the hand, when, if it
is gently insinuated without pressure or traction, a rather thorough
examination of the entire cavity can be made. The sensations ex-
perienced by a patient during a carefully made examination of this
kind is that of a vague intra-abdominal sensation, variously described
as a weight or fulness, becoming cramp-like if traction or pressure is
exerted.
It may often be found satisfactory to make such an exploration
under local means, then resorting to a light general anesthesia if
conditions are met with which cannot be easily undertaken by local
means alone.
Local anesthesia is not the method for routine work within the
abdomen, although in the interest of the patient many of the more
serious operations may be undertaken by these methods alone; here it
THE ABDOMEN 339
should always be borne in mind that no traction upon a viscus is ever
tolerated.
If, on exploring through a midline incision, an appendix or diseased
gall-bladder is encountered, separate incisions should be made over
these parts rather than attempt to displace them toward the
midline.
Many conditions of the patient may contra-indicate general anes-
thesia; it may then be advisable to attempt the more serious and
complicated procedures when the indications are urgent. Very ill
patients, and those suffering from the toxic effect of disease, often
have their general sensibility so reduced that they make favorable
subjects, provided they are not dangerously weakened or the field
of operation is not actively involved in inflammation; even in some
greatly weakened and reduced patients the danger of a general anes-
thesia may be greater than the difficulties likely to be encountered
with local anesthesia; it may, therefore, be advisable to proceed by
these methods. In some cases the combined method of operating is
advisable, using infiltration with light or superficial narcosis (see chap-
ter on this subject). In all intra-abdominal operations of any severity
the preliminary hypodermic of morphin, # to # gr. with Scopolamin
+}o to Tºo gr., should always be given one hour before operation.
The Stomach.-Simple operations upon the anterior wall of the
stomach when uncomplicated are quite easily performed under local
anesthesia by infiltration of the entire abdominal wall and sub-
peritoneal tissue in the line of the proposed incision, as already ex-
plained, making the incisions slightly longer than under a general
anesthetic; the cavity is opened, the wound lightly retracted, and the
stomach operated upon in position, or the viscus caught with a Sponge-
holder or the fingers and gently drawn out; if care is exercised not to
pull upon its attachments, no pain is produced. In this way we have
operated in many cases, and always with perfect satisfaction. It is
quite easy to perform gastrotomy for the removal of foreign bodies
or the examination of the interior of the stomach; also gastrostomy
by the Ssabanajew-Frank or other methods, or the Heinecke-Miku-
licz operation for hour-glass contraction, when unaccompanied by
surrounding complicating conditions.
Gastro-enterostomy and gastric resections are now no longer
novelties under local anesthesia. The early and extensive work
done by Mikulicz, and later by Braun, Lăwen, Bakes, and a host of
others, especially Finsterer with his classic contributions upon this
subject, have placed this method of operating upon a firmly estab-
340 LOCAL ANESTHESIA
lished foundation, and secures for it a recognition among other ac-
cepted procedures.
In posterior gastro-enterostomy by the “no-loop method,” the
operation now generally performed, the posterior stomach wall is as
tolerant of operative intervention without discomfortas is the anterior;
to secure access to it the mesocolon, in the usually selected non-vascu-
lar area, is first freely infiltrated between its layers before it is divided
and the stomach seized. In drawing the omentum and transverse
colon out of the field and displacing it above, as is usually done, they
-
-
Fig. 77-1, Line of anesthesia for exposing stomach. Upper oblique line is for
additional incision for Ssabanajew-Frank gastrostomy; 2, for exposure of gall-bladder; 3,
appendectomy through straight rectus incision.
should be carefully covered with wet towels (saline solution), as their
prolonged contact with the air may excite some complaint. After
infiltration of the mesocolon no further infiltration is necessary, and
the various steps of the operation are carried out the same as under a
general anesthetic.
For gastric resections the gastrocolic and lesser omentums must
be freely infiltrated between their folds for an area some little distance
beyond the proposed field of resection; this should not be undertaken
by local anesthesia alone, except under conditions of free mobility of
the stomach.

THE ABDOMEN 341
Finsterer, in his latest contribution to this subject in the “Beiträge
zur Klin. Chir.,” 1912, cites in detail a large number of resections
and gastro-enterostomies performed by purely local means. The
notable differences observed between such operations and similar
Ones performed under general anesthesia was the marked absence from
shock, lung, and renal complications, and almost a total absence of
postoperative vomiting and gastric distention, viscious circle, etc., as
there is not that paralysis of the stomach walls which follow such
operations under general anesthesia.
In colostomy for the establishment of an artificial anus the same
may be said here as for the stomach—the operation is quite easy and
satisfactory where the mesentery is not pulled upon. The later
opening of the bowel after a day or two, when adhesions have taken
place, we have never found accompanied by any pain; the excess of
tissue can be trimmed down level with the abdominal wall by either
knife, scissors, or cautery.
The Appendix.-The opening of a simple appendicular abscess when
in contact with the abdominal wall involves no greater difficulties
than an abscess situated elsewhere, and is always suitable for opera-
tions under local anesthesia. The removal of the appendix is a differ-
ent matter; in the presence of inflammation or extensive adhesions
the operation is never suitable for local measures alone; again, we
never know where the appendix will be found, whether lying loose on
the intestines in its usual position, bound down to the surrounding
structures, attached in the pelvis, embedded in the posterior abdominal
wall or retrocecal. The ease with which the appendix can be removed
in non-inflammatory cases depends entirely upon its position; when
lying loose and easily accessible we have quite frequently removed it
without any difficulties or pain to the patient, but always infiltrate
lightly the meso-appendix, as its ligation will cause pain, taking care
not to enter a vein in making the injection; when lying in other less
accessible positions, by sufficiently enlarging the abdominal incision
to permit free access, it can be fairly satisfactorily separated from other
attachments, when not too extensive, by lightly infiltrating these
lines of attachment with the anesthetic solution. On one occasion the
author removed, with but very moderate discomfort to the patient,
a retrocolic appendix by infiltration of the attachments of the cecum
and colon to the abdominal wall as well as the retrocolic space, then
divided these attachments and rolled the colon inward. Similar
methods of procedure can be resorted to elsewhere.
Gall-bladder.—Operations upon the fundus of the gall-bladder
342 $ LOCAL ANESTHESIA
for purposes of drainage in cholecystitis, or for the removal of stones,
are quite easily and painlessly performed when the bladder is fairly
accessible and not contracted or bound down by adhesions.
As traction will cause pain this should be carefully avoided;
scooping out stones or passing in forceps to extract them if cautiously
done will excite no complaint. Where stones are found in the cystic
or common duct, or the bladder small and contracted or badly adherent,
the case is hardly suitable for local anesthesia alone.
The Liver.—Operations upon the right lobe for abscess are best
operated by the transthoracic route, which has been described in
operations upon the thorax. Abscesses of the left lobe are quite
easily operated over their most prominent points; in these cases the
liver is usually already adherent to the abdominal wall, and a simple
incision under infiltration is all that is necessary; when it is not ad-
herent, it is first secured by sutures through its capsule before opening;
this is not, as a rule, painful, but should complaint be made light in-
filtration of the capsule will be sufficient to control it.
Intestines.—Resection of the bowel has been done satisfactorily
under local anesthesia. In typhoid perforation Dr. Harvey Cushing
reviews 5 cases, and notes their decidedly favorable postoperative
condition when compared with such cases (perforation or suspected
perforation) operated on with a general anesthesia, and comes to the
following conclusions: sº
“In consideration of the inevitable fatality of intestinal perfora-
tion in typhoid fever, and in the face of extreme difficulties of diagnosis
which often attend this complication in its early, and from the surgical
standpoint its elective, stage, it can be understood that a prompt
exploration, could it be unattended by risk, would be most desirable.
From the discussion and reports of these cases it would appear that
in certain surroundings such an exploration under local anesthesia
can be satisfactorily accomplished painlessly and without exposing
the patient to danger.” -
Dr. Mitchell, in discussing the same condition, has the following to
say: “The danger is practically eliminated by the use of local anes-
thesia, and at the same time the necessity for a hurried operation is
practically done away with. The knowledge that a cocain explora-
tion is without danger must lead one to explore, without hesitation,
many cases where a positive diagnosis would be demanded before sub-
jecting these patients to a general narcosis. Typhoid patients, as a
rule, are ideal subjects for local anesthesia.”
It will be seen after a study of the above that the clinical test on the
THE ABDOMEN 343
human subject agrees rather with the findings of Lennander than
with those of the animal experimenters, but without discrediting the
value of the latter. What effect in man the anesthetic solution, in-
filtrated in the abdominal wall, has upon the sensibility of the intra-
abdominal organs through its central action must indeed be very
slight, if any, and, at least for the present, has not been demonstrated
in man. It will also be seen from the range of operations mentioned
that the abdominal cavity is in many ways a free field for exploration
under local anesthesia, which is often limited as much by skill, dex-
terity, and gentleness of the operator as well as by the fundamental
principles and limitations already laid down.
Lipectomy.-This operation is quite easily, quickly, and satis-
factorily performed under local anesthesia. The procedure, however,
is more often done as a final step following laparotomy, hernia, or
other abdominal operations performed under general anesthesia.
Many Stout people seek relief for excessive abdominal fat who are in
apparently good health, but to whom one may hesitate to administer
a general anesthetic owing to their excessive obesity; in these the
operation is particularly inviting under local anesthesia, and becomes
more so in the presence of any organic lesion.
The length of the incision and mass of tissue to be removed may, in
the minds of the uninitiated, preclude the possibility of its being satis-
factorily done under purely local methods; this, however, is not the case.
The procedure should be undertaken as follows: Select any point
along the proposed line of incision, and with the small hypodermic
syringe produce an intradermal wheal, using solution No. 1 (o.25 per
cent. novocain with 2 or 3 drops of adrenalin to the ounce) then with
the large Io c.c. syringe and long fine needle enter at this point, di-
recting it subcutaneously along the line of the proposed incision, in-
jecting the solution as the needle is advanced; another introdermal
wheal is now made, just over the point where the long needle stopped;
the long needle is inserted at this point and continued as before (Fig.
78). The above is repeated until the entire circumference of the mass
to be removed has been infiltrated along the proposed line of incision.
(See illustrations in chapter on Principles of Technic; also Hacken-
buch, Plan of Anesthesia, same chapter.) Having completed the
above the long needle is now directed down into the depths of the
mass, at almost right angles to the surface, through the line of infil-
tration, and the depths of the mass freely infiltrated, inserting the
needle at intervals of every few inches. Fat itself has no sensation,
but many nerves come through the mass on their way to the skin,
! 344 LOCAL ANESTHESIA
and these should be blocked by this deep infiltration. As the fatty
layers are divided these nerves can often be seen in the glistening
mass before they are cut, and should receive additional injections if
any question exists regarding the thoroughness of the infiltration.
These nerves often accompany blood-vessels, which aids in their
more ready recognition. Blood-vessels, except the smallest, when
unaccompanied by demonstrable nerves should also be blocked, as
nerve-fibers exist in their sheaths and walls.
Fig. 78.-Line of cutaneous anesthesia and points for making deep injections down to
abdominal muscles for lipectomy.
Large amounts of solution are often needed for the removal of the
fatty masses, and for this reason the content of adrenalin should be
somewhat reduced from that usually employed for smaller operations,
2 or 3 drops to the ounce being sufficient.
The possibility of such low-grade tissue as fat suppurating follow-
ing its infiltration, as in the above operation, has been advanced by
some as an objection to its use; this, however, I have not found to be
the case in my hands.
The following case illustrates the possibilities in this direction:
Mrs. L., rather short, middle-aged woman, weighing 285 pounds, with cardiac and
renal lesions. For many years the abdominal fat had been accumulating, until for some

THE ABDOMEN 345
time prior to operation a large fatty fold hung from the abdomen over the pubes, pro-
ducing an unsightly appearance, seriously interfering with her movements and comfort.
She had long sought relief, but being an unfavorable surgical subject had been refused
operation.
She was operated on June 16, 1913, by the method outlined above and a mass of fat,
weighing 13% pounds, 29 inches long and 14 inches wide by 4% inches thick, was removed.
One quart of oz.5 per cent. novocain solution being required for the procedure no pain or
shock was experienced by the patient. Recovery, except for some gastro-intestinal dis-
turbance, was free from incident, the wound healing very satisfactorily. Specimen shown
in Fig. 79.
As a final proposition, it may be stated that where the intra-ab-
dominal condition presents inflammation with adhesions that a resort
may be had to the paravertebral method of anesthesia discussed under
Fig. 79-Fatty mass: weight, 134 pounds, 29 inches long, 14 inches wide, and 4% inches
thick, removed under local anesthesia.
this heading; or, where it is desirable to lessen or reduce to a minimum
the general anesthetic, the abdomen can first be opened by local anes-
thesia, determining just what is to be done, when resort may then be
had to light general anesthesia, combining infiltration of the region
operated upon to block all afferent nerves preventing shock or other
reflexes, as discussed in the chapter on Anoci-association.
Many procedures not discussed in these pages may be carried out
by an application of the principles laid down in the general remarks
on this subject. -

CHAPTER XVIII
HERNIA
“ONE of the most notable benefits that surgery has derived from
the introduction of cocain has been the successful local anesthesia
of the hernial regions, notably the inguinal region.
“One of the earliest applications of local anesthesia by the use of
cocain for the relief of strangulated hernia was made by an American
surgeon (Hewlett, 1887). Since that time the reports from German,
French, Italian, and American clinics have so steadily increased that
it would be difficult to even mention the names of the operators with-
out the risk of serious omission.
“It would be difficult to trace the history of cocain to its first ap-
plication in the radical cure of hernia, but it is evident that many
operators in this country and Europe began to resort to this mode of
practice even in the early days of cocain technic. Reclus, in his book
on ‘Cocain in Surgery’ (1895), describes his method of infiltration
(with I per cent. Solution) for the cure of hernia, which he has per-
formed as a typical procedure many times. Ceci, of Pisa, in a contri-
bution (“Semaine Medicale, Paris, as early as 1899, vol. xix, p. 41),
states that by combining the statistics of his clinics in Genoa and
Pisa (1885–1899) he had collected 543 radical operations for hernia, of
which 363 were anesthetized with cocain alone. Ceci made use of
a 5 per cent. cocain prepared with 3 per cent. boric acid solution.
He believed in deep infiltrations, including the hypoderm and the
subaponeurotic layers in his primary injections, without reference
to a separate analgesia of individual nerves of the region. The large
number of personal observations reported by Ceci alone indicate that,
up to 1899, great success had already been attained in the radical cure
of hernia by the earlier methods of direct local infiltration” (Matas).
Since these early days these contributions have been too numerous
to mention, and the performance of this operation under local anes-
thesia is now no longer a novelty.
The value of the neuroregional method had not been tested in
this operation until 1897, and it remained for Dr. Harvey Cushing,
of Johns Hopkins University (Prof. Halsted's Clinic), to do so.
346 -
HERNIA 347
And again, in 1900, in the “Annals of Surgery,” he thoroughly
discusses this method, which has been tried and accepted the world
over by all who resort to local anesthesia for this operation.
INGUINAL HERNIA
There is probably no commonly performed major operation that
is more inviting to local or regional methods of anesthesia than in-
guinal herniotomy. This is so on account of the superficial position of
the parts, the anatomic arrangement, and the course and distribution
of the nerves involved. -
Such operations under local methods require a thorough knowledge
of anatomy; often a more accurate knowledge than is required for
the same operations under general anesthesia. It, above all, makes
of us nerve anatomists, and forces us to respect and preserve from
injury all nerves encountered. While during the operation we are
principally concerned with the sensory functions of the nerves, we must
not lose sight of the fact that most nerves are motor and trophic, as
well as sensory.
Division of an important nerve may be followed by muscular
atony and relaxation of the parts, and, in the case of herniotomy, be
followed by a recurrence of the trouble or an unpleasant sagging of
the scrotum in case the cremaster muscle is paralyzed by division of
the genital branch of the genitocrural, or a possible atrophy of the
testicle. Of course, such injuries should not occur in the hands of
careful operators even under general anesthesia, but under local
anesthesia there are greater precautions taken, as we are forced to
recognize and respect each individual nerve.
One of the many advantages of local over general anesthesia, as
mentioned elsewhere, is particularly emphasized here in the absence
of vomiting; these efforts, if prolonged or severe, may compromise
the results of the operation by loosening sutures and favor a recur-
rence of the trouble. This is particularly likely to be the case in
large or complicated herniae, where often extensive plastic resections
are necessary to secure a satisfactory closure. For this, if for no
other reason, should the local method be preferred, and I believe
that a comparison of statistics will show a lesser percentage of re-
currences following closure in this way.
The size of the hernia is no contra-indication for this method, nor
is the age of the patient, providing he is enjoying fairly good health;
in fact, old age is particularly favorable to all local anesthetic pro-
cedures. Many of these old subjects may be refused operation by
348 - LOCAL ANESTHESIA
general anesthesia, when they can be safely and easily operated upon
by this method. It is advisable that these old patients should be put
to bed for a day or two before operation to see how they stand confine-
ment, and to enable them to learn to empty their bladder and bowels
in the recumbent position. 4.
Another important consideration which applies to all cases, but
more particularly to the aged, is that nutrition is not interfered with,
as there is no disturbance of the gastro-intestinal tract. A light
meal is always preferred just before operation, but nourishment
should be restricted to liquids after operation, excluding milk for the
first day or two. If the subject is very feeble, stimulating drinks,
such as coffee, toddy, or hot tea, can be administered during the prog-
ress of the operation. By handling feeble and aged subjects in this
way—by local anesthesia—many can be safely carried through an op-
eration for hernia without any operative or postoperative disturbance
whatever, who would most probably succumb, if not to the operation,
at least to the necessary postoperative disturbances following general
anesthesia.
Nerves.—There are three nerves with which we are principally
concerned in inguinal hernia—the iliohypogastric, ilio-inguinal, and
genitocrural.
The skin over this region receives branches from several of the
surrounding nerves, especially the last dorsal, but, as it is infiltrated
directly, these do not especially interest us (Figs. 80, 81).
The iliohypogastric nerve perforates the transversalis muscle at its
posterior part, near the crest of the ilium, and gives off its iliac branch,
which descends; the hypogastric branch continues forward between
the transversalis and internal oblique, perforating the internal oblique
just above and a little to the outer side of the internal ring. It then
runs transversely inward toward the middle line on the surface of the
internal oblique, and just above and a little to the outer side of the
external ring pierces the aponeurosis of the external oblique, and is
distributed to the skin of the hypogastric region. -
The ilio-inguinal nerve appears in the field after perforating the
internal oblique at or near the internal ring and descends along the
lower part of the inguinal canal; it terminates by distributing fibers.
to the side of the scrotum and thigh. This nerve is not constant, and
occasionally is found joined to the genital branch of the genitocrural
to form the external spermatic nerve. -
The genitocrural nerve, its genital branch, appears at the internal
ring and passes down the back part of the spermatic cord into the
HERNIA 349
First intercostal nerve
r
Anterior cutaneous
branch, second
intercostal
Lateral cutane-
ous branches,
fourth inter-
costal
Sixth rib-
Sixth inter--.
costal nerve
Anterior
Cufaneous
E-> branches,
eighth
intercostal
Twelfth rib -*
Muscular --A-
branches
Twelfth inter--__
costal nerve
Transversalis ---
muscle
Iliohypogas----
tric nerve • Navel
Muscular -- - -
branches -
- - - -- Rectus muscle
Cutaneous branches.
iliohypogastric
Internal oblique
muscle
Anterior cutaneous
|-> branches, twelfth
intercostal
Ilio-inguinal-
nerve
Inguinal ring
- wº
Fig. 80-Course and distribution of the intercostal nerves. (After Spalteholz.) The
intercostal and oblique abdominal muscles are removed. (From Braun.)
scrotum, where it supplies the cremaster muscle, testicle, and other
contents of the scrotum. The skin of the scrotum receives fibers from



























35O LOCAL ANESTHESIA
the inferior pudendal branch of the small sciatic and from the super-
ficial perineal branch of the pudic, in addition to the ilio-inguinal
nerve already mentioned. &
It will be seen from a study of the above that after the skin is
passed all nerves entering the field emerge at or near the internal ring,
and it is consequently here that we inject most of our solutions.
^
2^
_-T
# ~\-Lateral cut of 12.d.
/~/.
| \ . 33 ...Ant supspine
anterior cutan's ºf adº ** * * * * sº e s ss * \ º
KW;
\ –
*Lat.cut of 1.1
anterior Cutan's ºf 1.lunº ^->
(ilio-hypog)
immº-f. () 42% º !// X
** (Mº.)
\
/ \ ~~
\
\ ...-- ./’ \
Ş. Y \ \
\ \ \ \Cºurbr. \
\ \ \Gek. rual
|ilio guin. i.
QMT |
(MGenital.hr |
7~~~~~~s \; Gen.Cruſº ſ
Superfic pºrineal tº gº tºº gº tº e{ **…* ºr *—--~~ \ A
of pudic 3\\ S. _ ! ~ \ _2^ \
infer pudendai 1-2 S \
§ smáll Sciatic 1– Awºshiff
4-r
Fig. 81--Sites for local anesthesia in the inguinal region. (After Cushing.)
Preparation for the Operation.—Preliminary hypodermic or mor-
phin, ; gr., with scopolamin, Hºw gr., one hour beforehand.
Four ounces of solution No. 1 (novocain, o.25 per cent.; sodium
chlorid, o.o.4 per cent.), to which add 15 drops of adrenalin solution
(I : Iooo). If the hernia is very large, it is well to have on hand more



HERNIA 35I
than the 4 ounces. Small hernias may not require this much, but it is
well to have an ample supply.
Two small hypodermic syringes and one large Io c.c. syringe,
with long fine needles, or a Matas' infiltration apparatus—all well
tested beforehand to be sure they are in good working order.
Some operators prefer to inject the cases about fifteen minutes to
one-half hour beforehand, and allow them to wait for the solution
to diffuse and become fixed in the tissues. This practice, while ad-
visable elsewhere, we do not find necessary here, and proceed at once
with the operation. Also some prefer to use a 1 per cent. novocain
Fig. 82.-Long needle passed through intradermal station to reach position of iliohypo-
gastric nerve beneath tendon of external oblique.
solution to infiltrate the nerves as they are encountered, but, as all
the nerves concerned are very small, it is unnecessary to use any but
the ordinary infiltration solution (No. 1).
Begin the injection with the small hypodermic syringe at the high-
est point of the proposed incision, at the upper and outer part of the
field, about 1% inches internal and slightly below the anterior spine of
ilium. Make the injection intradermally. With the large syringe and
long needle enter at this point, directing the needle downward to the
subcutaneous tissues (Fig. 82), and inject about 4 ounce in this posi-
tion; another 4 ounce is injected subcutaneously along the proposedline
of incision by advancing the needle in this direction (Fig. 83), inject-
ing as the needle is advanced. If the patient is very stout and there

352 LOCAL ANESTHESIA
is much subcutaneous fatty tissue, more than this may be needed, but
in the ordinary case the above is sufficient.
While we are waiting for these subcutaneous injections to diffuse,
the infiltration of the skin is finished by starting at the already in-
jected point on the skin, proceeding downward and inward intradermally
the full length of the proposed incision. After this had been done,
the incision can be made at once and carried down to the aponeurosis
of the external oblique. Expose this freely over the site of the inter-
nal ring, and with the large syringe inject about 4 ounce of solution just
under the aponeurosis at this point. Now, while waiting for this to
Fig. 83–Needle is partially withdrawn from position shown in Fig. 81 and directed sub-
cutaneously toward pubes.
act, here secure and tie any superficial vessels that may be necessary,
and expose the rest of the field by gauze dissection. Then, slit up the
aponeurosis of the external oblique to above the internal ring, retract,
and you bring into view the iliohypogastric nerve. This has probably
already been anesthetized by the last injection, but if there is any
doubt it can be injected intraneurally or perineurally with the small
hypodermic syringe.
Retract upward the internal oblique and transversalis to better
expose the internal ring. If the ilio-inguinal nerve is seen on the
lower side of the cord (Fig. 84), infiltrate it at once high up; if not
seen, inject circumferentially around the neck of the cord several small

HERNIA 353
syringefuls of solution. This will permit it to be freely handled and
the ilio-inguinal and genitocrural nerves looked for-the ilio-inguinal
on the lower side of the cord and the genitocrural behind. If any
trouble is encountered in finding them, and it is likely that the cord
or scrotal contents will be handled, then a free infiltration of about
} oz. around the neck of the cord will suffice and will reach both nerves
involved. If such an injection is made, care should be exercised not to
enter any veins. It is, of course, far preferable to locate the nerves.
The sac is now picked up and opened and any contents replaced in the
cavity. If they are adherent, their separation does not cause pain.
Fig. 84-1, Iliohypogastric nerve; 2, ilio-inguinal nerve; 3, spermatic cord; 4, hernial
sac dissected free. The genitocrural nerve is not seen, as it lies within the cord on its
posterior aspect.
Omentum may be resected, if necessary, without pain." A finger is
now passed into the cavity through the neck of the sac, and two or
three small hypodermics of the solution distributed subperitoneally
around the neck, either from within the sac or by passing the needle
down around it from the outside (Figs. 85, 86). The sac can now be
dealt with by any method preferred—if small, excised; if large and ad-
herent, it can be divided, slit up, and left in situ, to be eventually
absorbed, or it may be entirely removed.
* Any large vessels encountered in extensive resections of the omentum should be
blocked, as these are sensitive; otherwise the omentum has no sensation.

23
354 - LOCAL ANESTHESIA
-
Fig. 85.-Method of making injections around neck of sac, with finger within sac.
Fig. 86 —Method of making subperitoneal injections around neck of sac. Sac slit up and
held open and injected from within.
An existing varicocele or any other complication should be dealt
with now and requires no further infiltration. The testicle may also
be exposed and handled if necessary. It should be borne in mind, how-


HERNIA 355
ever, that any undue traction upon the cord by pulling upon the parts
within the cavity will cause pain, but none is otherwise experienced.
The neck of the sac can now be closed—by crushing, if large, and
ligated; or sutured, if preferred.
The operation usually performed by Professor Matas and his staff
is the Ferguson-Andrews. Here the cord is not disturbed, and con-
Sequently may require less preliminary injection, as it is left in its
bed and all structures Sutured over it, the aponeurosis of the external
oblique being overlapped. However, the operation can now be com-
pleted by any of the accepted methods—the Bassini or any of its
modifications. -
If the above technic is followed absolutely no pain should be felt
by the patient; where pain is inflicted the technic is at fault. In the
hands of a skilful operator an ordinary hernia can be closed by using
not over 3 oz. of solution (we often use much less), and the time con-
Sumed is not over five or ten minutes longer than would have been
required with general anesthesia. -
The following histories may prove interesting:
Flood, aged seventy-five, Ward 9, an old and feeble man. Entered the service for
the removal of epithelioma of right temporal region, and while convalescing from the
operation, which was done with local anesthesia, a large inguinal hernia of the left side,
of fifteen years’ duration, became incarcerated and irreducible. He was operated on
June 26, 1908, by the method described above, and was discharged cured in two weeks,
with no recurrence since. This was a particularly satisfactory case, in view of the extreme
feebleness of the patient.
Pear, aged sixty-four (Fig. 87). Left inguinal hernia of thirty-four years’ duration
with enormous sac, extending to near the knee. The contents of the sac had not been
reduced for years; the photograph gives a good idea of the condition. The inguinal
ring was large enough to admit three fingers. In view of marked arteriosclerosis, with
renal and cardiac lesions, the operation was performed by the above-mentioned method
on August 27, 1908. A large part of the omentum was adherent to the Sac and much
thickened and had to be resected. A portion of the rectus muscle was transplanted to
close the inguinal opening. Some of the redundant skin of the parts was resected. The
operation was entirely painless, with union by first intention, and the patient was up in
two weeks. This case was a bad hernia and a severe test of the method, and clearly de-
monstrated its usefulness and feasibility in these cases. I have recently seen the case,
and he had remained well, with no sign of recurrence.
In case the hernial ring is very large, it may be necessary to loosen
the internal oblique and transversalis from the edge of the rectus So as
to enable the conjoined tendon to be brought down; in case this is
necessary, and the dissection be carried very high, some additional
infiltration at this point may be needed, and should be made directly
into the tissues to be dissected.
356 LOCAL ANESTHESIA
In the event that the hernia sac contains a large amount of intra-
abdominal contents that cannot be replaced before operation, this can
often be done, after the sac is freely exposed and liberated and the
internal ring enlarged, by taking the sac up in the hands and resorting
to manipulation. If the contents are not readily replaced do not
open the sac too freely at once, as the too long exposure of a large
length of bowel may cause unpleasant intra-abdominal discomfort
and some complaint on the part of the patient, but make a small slit
near the neck of the sac and explore its contents with the finger. The
contents of these large hernia sacs are, as a rule, mostly omentum,
Fig. 87-Large irreducible hernia operated on by author under local anesthesia. Sac
contained omentum and intestines; large part of omentum was resected.
with a small loop of bowel. If much bowel is encountered, it can be
replaced in this way usually without much difficulty, unless adherent.
If the omentum is found hard and fibrous from its long sojourn in the
sac it will require resection, but, unless badly damaged, it should not
be sacrificed, as it is an organ of many valuable functions.
The exposure of the omentum. never gives rise to any discomfort,
and its resection causes no complaint, as it has no sensation; but
large vessels within it are sensitive, and should first be blocked before
ligation or division. -
In the case of very large herniae, where it is necessary to carry

HERNIA 357
the skin incision well down over the scrotum, the skin must be infil-
trated all the way.
In Strangulated hernia, general anesthesia is contra-indicated, and
should rarely, if ever, be used. In very severe and prostrated cases
the general anesthetic may add sufficient additional depression to
cause a fatal issue. The Sac should here be exposed and opened under
infiltration. If the patient is very weak a radical operation should
not be attempted at the time, but the bowel, if gangrenous, opened
and drainage permitted. It will here frequently be found that the
bowel is adherent around the ring and the general cavity walled off.
If this is not the case, a few sutures and packing can be resorted to to
close off the cavity and the bowel at once opened. The improvement
permitted by this procedure revives the patient and, after all gan-
grenous material has come away, the ends of the bowel can be ap-
proximated by the Murphy button or suture.
We then wait for good union to take place and the wound to be-
come clean and covered with healthy granulation, when it can be
closed with a small drain. The following case illustrates this type:
Mr. S., aged seventy-two. Had had a large inguinal hernia since he was seventeen.
It had frequently become incarcerated, but he was always able to reduce it until a few
days prior to my seeing him, when it again became incarcerated and all efforts at reduc-
tion failed, strangulation following. Patient was very feeble, pulse almost imperceptible,
temperature subnormal with cold extremities, and almost constant stercoraceous vomiting.
Under local anesthesia the sac was opened. The bowel and fat attached to it were found
gangrenous, with a large quantity of foul fluid in the sac. The neck of the sac was securely
protected with sutures, packs, and rubber tissue, the gangrenous fat cut away, and the
loop of bowel opened at the distal end. The patient revived at once, all vomiting
ceasing, next day was in a rolling chair on the gallery, and in a few days was sitting up.
Nourishment had been at once resumed, and his improvement was noticeable daily.
In ten days the bowel was closed by suture, and two weeks later the wound, now being
quite healthy, closure under local anesthesia was performed. The bowel, freed from
the old sac, dropped back into the cavity, the wound enlarged until the anatomy became
apparent, and the parts then closed with two rubber-tissue drains, one within the cavity
and one subcutaneously. The Fowler position was used for twenty four hours, then dis-
continued, and the drain removed in three or four days. Recovery was without incident,
the patient being discharged about three weeks later. This illustrates a type of case which,
I believe, if handled any other way would have resulted fatally.
Reclus very justly refers to operations for strangulated hernia as
“the triumph of cocain.” In strangulation it is the anesthetic of
election, and it is only in special conditions, such as in hernia of unu-
sually large size, with eventration of the abdominal contents and when
extensive adhesions exist, that he would prefer a general anesthetic.
In advanced strangulations, with vomiting of intestinal contents, the
dangers of septic pneumonia and secondary renal complications from
358 LOCAL ANESTHESIA
chloroform and ether are specially to be feared, and more particularly
in the aged. Then, again, colostomy for strangulation is an urgent
operation which, in country practice, frequently compels the surgeon
to depend upon unskilled assistants. Under these circumstances the
value of a local anesthetic entirely under the control of the operator
becomes especially apparent. It is not surprising, therefore, that
Mehler enthusiastically asserts that he who has tried local anesthesia
in these conditions will never feel inclined to return to general anes-
thesia, unless compelled to by pressure of unusual circumstances.
FEMORAL HERNIA
This hernia, except in very fat people, is easily operated upon
with local anesthesia, and is best suited to the infiltration method.
Regional anesthesia cannot be employed, as the nerve-supply is from
Fig. 88.-Line of cutaneous anesthesia for femoral hernia.
many sources and reaches the field from several directions, all being
small branches. This method of procedure will likely vary, accord-
ing as to whether or not the patient is stout or thin, and whether the
hernial sac can be readily defined from the surrounding tissues.
In stout persons or in poorly defined sacs an incision had best be
made in the long axis of the tumor, infiltrating layer after layer, and
cutting as we go (Fig. 88). After the sac has been reached and
defined the tissues at its sides and neck can be infiltrated, care being
taken to locate and avoid the femoral vein which lies just to its outer
side, and, on account of the sac rising forward, often a little behind.
In case the patient is thin and the sac well defined a more satisfactory

|HERNIA 359
plan can be followed by making a circumferential injection around
the Sac Subcutaneously; or, as recommended in umbilical hernia, the
Sac can be opened early in the operation and a finger passed down
within, which is used as a guide to the needle which is passed down
along the outer wall infiltrating the tissues as far as the neck.
First anesthetize a point in the skin near the edge of the sac with
a Small hypodermic syringe. If the Matas infiltration apparatus with
a curved needle is convenient, it will be found very useful here; if
not, the large syringe with a long needle will answer. The advantage
here of the Matas apparatus with the curved needle is that the
entire circumference of the sac, unless very large, can be reached and
infiltrated from a single point of puncture of the skin; if a straight
needle is used several punctures will have to be made.
First advance the needle closely under the skin, then through the
deeper subcutaneous tissues in all directions around the sac on the
outer side, taking care not to penetrate beneath the fascia lata for fear
of injuring the femoral vein, but on the inner side a much greater
depth can be penetrated without fear of injury.
It may be necessary to avoid the Saphenous vein at the lower por-
tion. The precaution mentioned elsewhere, when injecting in the
neighborhood of large veins, should here be observed, of injecting only
when the needle is being advanced or withdrawn, and never when the
point is stationary, as a vein may be entered and a large quantity of
the solution thrown directly into the circulation. If a vein, should
be pierced with a fine needle no serious consequences will result.
The injection by the above method is made very quickly, and all
nerves entering the field from any direction are bathed in the solu-
tion and anesthetized. It is unnecessary to inject the skin along the
proposed line of incision if a few minutes' delay is permitted for the
solution to diffuse. This plan of Lennander, of waiting fifteen to
twenty minutes after the injection, is of advantage here. But in
case it is desirable to proceed at once, and the skin in the middle
line is not anesthetic, it can be infiltrated intradermally and the in-
cision made at once, as the deeper parts will be found well anesthetized.
Before opening the hernial sac it should be observed whether or
not it is the bladder, which is very common in these herniae, and may
be opened in looking for the peritoneal investment.
The neck of the sac is freed and Gimbernat’s ligament divided,
when reduction is usually easy. Closure can then be accomplished
by any recognized method, after first anesthetizing the neck of
the sac.
360 LOCAL ANESTHESIA
The solution used here is the same as for inguinal hernia (No. 1,
novocain, o.25 per cent.; sodium chlorid, o.o.4 per cent; and adrenalin,
Io to 15 drops).
UMBILICAL HERNIA
In very fat individuals with large herniae and many adhesions and
tense abdominal walls this operation may be difficult under local
Fig. 89–Method of injection around umbilical hernia. (From Braun.)
anesthesia, nevertheless it can be performed; but in thin or moder-
ately stout patients, unless the condition is very severe, it can be
quite satisfactorily performed.

HERNIA 361
In all these operations the mechanical difficulties are very much
lessened by putting the patient to bed for a few days, on restricted
diet, with daily laxatives. This relaxes the abdominal walls and
relieves the intra-abdominal tension, and approximation of the gap
can be much more easily obtained.
With Solution No. 1 several stations in the skin are anesthetized;
if the hernia is small, one on each side; if large, one above and one
below, in the median line, in addition (Figs. 89, 90). By entering at
these points (Matas' infiltration apparatus or large syringe with long
needle) and passing the needle in all directions, a circumferential in-
jection is made into all the subcutaneous tissues, thus creating a zone
Fig. 9o-Cross-section through umbilical hernia, showing method of making deep in-
jections through abdominal walls. (From Braun.)
of anesthesia. If the underlying muscles are clearly outlined, and
there is no danger of going through them, these may be infiltrated
at the same time; otherwise this had better be delayed until they are
exposed. After a delay of from ten to fifteen minutes, to allow the
solution time to diffuse, the incision can be made. First, expose the
muscles and thoroughly infiltrate them down to the peritoneum, if
this has not already been done. While we are waiting for the last
injection to diffuse, bleeding points can be ligated and the sac opened
and its contents dealt with. By now the parietal peritoneum will
probably have become anesthetized, and the sac can be cut away
around the margin of the gap; if the peritoneum is still sensitive, a

362 LOCAL ANESTHESIA
long needle is passed through the opening into the subperitoneal tis-
sue and a moderate injection made in all directions. There will then
be no further Sensation.
In dealing with the contents of the Sac Omental adhesions cause
no trouble, and can be separated or divided without sensation. If
the intestines are adherent any very extensive manipulation may
give rise to cramps, but this can be avoided by infiltrating with a
fine needle the points of adhesion, care being taken not to enter the
bowel.
In closing these hernia the Mayo operation of overlapping is
usually considered the best, and can here be easily done.
It may often be found advisable to open the sac early in the opera-
tion after the circumferential injection and pass a finger down through
the ring; this is held under the edge of the muscle while the long needle
is passed down from without through the tissues, injecting the several
planes as it is advanced until it reaches the tissues just above the pal-
pating finger within the cavity. In this way the injection of the entire
field is made before the operation is well advanced without danger of
injuring the bowel by penetrating through the abdominal walls, and
will often be found the more preferable method of handling these cases.
The same procedure is used in postoperative herniae.
POSTOPERATIVE HERNIA
In selecting these herniae for operation by local anesthesia one
should be guided by the same general observations made regarding
umbilical hernia. In some of these cases the gap in the muscle wall
is considerable, often ragged and irregular, and difficult to close by
general anesthesia. Under local anesthesia these difficulties are not
increased, but often lessened, as you do not have the straining so often
encountered under general anesthesia. The patient can also better
take a position favorable to relaxation of the muscles, but particularly
valuable afterward is the absence of vomiting, which if severe or pro-
tracted may often jeopardize the results of the work. It is here
often highly valuable to have the patient remain perfectly quiet after
operation, as he is able to do following the use of local anesthesia.
These remarks apply equally to all herniae.
One difficulty encountered in postoperative hernia is the large
amount of fibrous tissue encountered, which mats all the Structures
together, but if a zone of anesthesia is created just outside of the
area no special difficulties are encountered.
Hernia in the midline should be dealt with the same as umbili-
HERNIA 363
cal herniae, by a complete circumferential injection around the gap,
thus sequestering all nerve-endings within the area.
Herniae just to either side of the midline will also require a circum-
ferential injection, as the nerve-fibers from the other side lap over the
midline some little distance; but where the hernia is some distance
removed, as is the case of those resulting from appendicular opera-
tions, a circumferential injection is not necessary. As all the nerves
in the anterior abdominal wall proceed downward and forward be-
Fig. 91.-Method of making crescentic line of anesthesia around postappendicular hernia.
Deep injections made through heavy dots.
tween the muscle planes, it is only necessary to make the injection in
such a way as to block these. Consequently, a crescentic-like area
of anesthesia on the outer side of the hernia will prove sufficient,
having the horns of the crescent to embrace the upper and lower ex-
tremities of the gap and carried as a wall of anesthesia from the skin
to the peritoneum. (See Figs. 80 and 91.) I have often closed large
postappendicular herniae in this way, and have found it very satis-
factory.

CHAPTER XIX
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC
OPERATIONS
GENITO-URINARY ORGANS
WHILE the pudic nerve is the principal source of innervation of
the deeper parts of these organs (Fig. 92) and is capable of a fairly
accurate blocking for regional anesthesia, the skin of these parts re-
ceives its nerve-supply from a variety of sources and cannot be dealt
with collectively except by such more or less central methods as
parasacral or epidural injections, thus blocking at one time the entire
innervation of the pelvis and a large part of the lower extremity.
The pudic nerve leaves the pelvis through the great sacrosciatic
foramen, crosses the spine of the ischium with the pudic artery, and
re-enters the pelvis through the lesser sacrosciatic foramen. Accom-
panying the pudic vessels, it runs downward, forward, and inward
along the outer wall of the ischiorectal fossa. In this position it is
about I inch internal to the tuberosity of the ischium. Here it gives
off its perineal and inferior hemorrhoidal nerves, then continues as the
dorsal nerve of the penis.
The inferior hemorrhoidal nerves, several in number, pass down-
ward, inward, and slightly forward from the above position, and are
distributed to the sphincters of the rectum and anal canal.
The perineal branches pass downward and forward to the perineum,
giving off branches to the muscles of these parts, and are distributed
to the skin of this region, branches passing forward to the scrotum in
the male and labia majora in the female. It also sends a branch to
the bulb of the penis.
The dorsal nerve of the penis pierces the posterior layer of the deep
perineal fascia, and runs forward along the inner margin of the ramus
of the os pubis between the two layers of deep fascia. Further for-
ward it pierces the anterior layer of the fascia and passes through the
suspensory ligament to the dorsum of the penis. In this position the
nerves on each side lie to the outer side of the artery (Fig. 93). It
364
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 365
Anococcygeal nerves
Anococcygeal lig
- Glutaeus maximus
… º. sacrotuberous lig.
- internal pudic art.
pudic nerve
--sacrospinous lºg.
Levator anſ
medial infer cluneal me.
inferior haemorrhoidal.
arteries
int. pudic - - inſ. haemor-
M. ºl - - *- _rhoidal and
vessels - - ** - - - - - perineaſ
- - - nerves
pudie
nerve
A. 2
* 2. -
Transversus/ - 2.
perinet º / /
-- * - - -
superfºrial. A * - * * periºral branches
ºrinear art." 2’ Af N * of 22st. Jem.
- f -
Salinder ºf º \ N. º, * an. Merve
ani externus ** *.
- -
- - **
Ischioravernosus’ \, º, dorsal nerve of penis
^ artery of urethral bulb
* y
Z \
/ an area
- art. ºn ents
Bulboºternosus’ 'f º
\
pasſerior scrotal arteries
corpus cavernosum of urethra posterior Scrotal nerves
Fig. 92–The nerves and vessels of the male perineum upon the left side, the
superficial perineal musculature has been exposed and the ischiorectal fat removed;
upon the right the transversus perinei superficialis has been divided, the urogenital
diaphragm incised, and the ischiocavernosus drawn slightly to one side. *=Bifurca-
tion of internal pudic artery into the perineal and penile arteries. (Sobotta and
McMurrich.)
gives off a large branch to the corpora cavernosum, and along the side
of the penis branches to this organ; its terminal filaments are dis-
tributed to the glans and prepuce.











366 LOCAL ANESTHESIA
Perineal branches of the small sciatic are distributed to the skin
of the posterior and lateral parts of this region, one branch larger than
the others; the inferior pudendal curves downward and inward around
the tuberosity of the ischium, and passes forward and inward beneath
dorsal artery of penis fundiſºn ligament
dorsal nerve ºf penis of penis
spºrmatic ror
dorsal vein of penis
external
inguina/
% ring
iſio-inguinal
- nerve
spermafir.
cord
external spermatic
vessels
| external
2^pudic vessels
*
pampiniformy
venous plexus
festicular art.
fascia of penis
anferior
scrotal vessels
dorsal vein 2’ -
of penis -
w
x subrufaneotts
vein of penis
Fig. 93–The vessels and nerves of the penis spermatic cord and scrotum as seen
from in front. The skin and the greater portion of the fascia have been removed from
the penis; the vessels of the right spermatic cord have been exposed by dividing its
coverings. (Sobotta and McMurrich.)
the superficial fascia and is distributed to the skin of the perineum—
scrotum in the male and the labia majorum in the female. The nerve
in its passage around the tuberosity lies about 4 inch to the outer side
of the bone, between it and the great sciatic nerve.
The scrotum, in addition to its branches from the pudic and in-








GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 367
ferior pudendal, receives cutaneous branches from other sources,
principally the ilio-inguinal, and probably, on its anterior part, a few
branches from the iliohypogastric. Its nerve-supply is such that all
operations done upon it must be through infiltration. The testicle,
spermatic cord, and cremaster muscle are innervated by the genital
branch of the genitocrural, but this nerve does not give any branches
to the skin overlying these parts.
The bladder receives two nerves on each side from the third and
fourth Sacral, which enter the organ near its base.
Method of Blocking Pudic Nerve.—The tuberosity of the ischium
is located as a landmark; the skin over a point about I inch internal
and in front of the tuberosity is now anesthetized; a large syringe,
containing a few drams of o.5o per cent. novocain solution, with 2 or
3 drops of adrenalin, and fitted to a long needle, is now used. The
needle is passed downward and outward toward the base of the tuber-
osity, varying in depth according to the stoutness of the individual,
but usually about 1% to 2 inches; at a point about ; inch from the base
of the tuberosity 2 or 3 drams of the solution are injected. The same
procedure is repeated on the opposite side; or, if preferred, the long
needle may be entered at a point 1; or 2 inches back of the anus in
the midline, after previously anesthetizing this point in the skin, and
directing the needle obliquely outward and upward toward the base
of the tuberosity of the ischium, guided by the finger within the rectum,
when 2 or 3 drams of the solution are injected about ; inch from this
bone. The method of making this injection is shown in Fig. Iog. The
needle is then partially withdrawn and turned in the opposite direction,
where the injection is repeated. These methods, however, are not
often used, but when resorted to for operations on the rectum the
perianal infiltration, as described later, should be made somewhat
more liberal posteriorly between the anus and the coccyx and well
into the subcutaneous tissue to reach the nerves that come into the
field from this direction. The uncertainty of reaching this nerve at
the point where it enters the pelvis with any degree of accuracy
for a paraneural injection has led to efforts to reach it from without
by an injection made through the gluteal region. This procedure has
been recommended by Franke, and is done as follows: The skin of
the gluteal region, at a point about over the spine of the ischium, is
located by a finger passed within the rectum, and the long needle
passed down from without through the anesthetized point and an in-
jection made in contact with the spine. Neither of these methods have
become very popular with others, and are rarely if ever used by the
368 LOCAL ANESTHESIA
author. The methods preferred are those described in dealing with
the different regions, as described later.
To anesthetize the inferior pudendal nerve an injection is made on
the outer side of the tuberosity of the ischium, where this nerve
passes close to the base of the process and between it and the great
sciatic.
The needle is entered in the perineum to the inner side of the
tuberosity and directed outward and upward, injecting as the needle
is advanced to a point over the base of the bone; the injection is
made after the needle is felt to pass the bone about 4 inch, usually
using about 2 drams of o.5o per cent. novocain adrenalin solution.
This, however, like the injection of the pudic, is uncertain.
THE PENIS
To anesthetize the entire organ a circumferential line of intra-
dermal anesthesia is carried around the organ at its root, as seen in
Fig. 94-Method of procedure for anesthesia of entire penis. (From Braun.)
Fig. 94. From this line two deep injections are made about 4 inch
on either side of the midline and carried down to the corpora cavernosa
(Fig. 93), showing the nerve-supply and (Fig. 95) the point of injec-
tion, using here about I dram of o.5o novocain adrenalin solution or
a somewhat more liberal injection of solution No. 1.
If the contemplated procedure involves the urethra, a smaller
quantity of the solution should be injected deep on either side of this

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 369
structure in the sulcus, between it and the corpora cavernosa. Should
a fine needle pierce the urethra in this injection no damage will
result. A small stationer's elastic band, used as a constrictor, should
now be placed around the base of the organ proximal to the injections,
but not too tightly, for fear of injury. After a few minutes' delay
anesthesia is produced. Gentle massage helps to diffuse the solution,
when any operation involving these parts may be undertaken, from
circumcision to amputation. Urethrotomy, internal or external, as
well as plastic work, involving the urethra or the rest of the organ,
Fig. 95–1, Shows line of anesthesia for suprapubic cystotomy; 2, points on each
side of midline for paraneural injection of dorsal nerves of penis; 3, area of anesthesia for
varicocele, hydrocele, or orchidectomy.
can now be painlessly done. The above is an excellent method for
the cauterization of extensive or phagodenic chancroids of this region
or for operations for paraphimosis.
The Oberst Method.—This is really a form of arterial anesthesia,
and, while ingenious and effective, may at times be followed by hema-
toma, and for that reason is not very popular with the writer.
A constrictor is placed around the root of the organ. A syringe and
fine needle filled with 1 per cent. cocain solution (which is the solu-
tion recommended by Oberst, though novocain could also be used)
is now injected in the following manner:

24
37o LOCAL ANESTHESIA
The needle is thrust well into the corpora cavernosa, and from 5 to
7 min. of the solution is injected (Fig. 96). This is repeated on the
opposite side. About 5 min. of the solution is injected into the sub-
cutaneous tissues on each side of the organ, and about the same
quantity on the undersurface around the urethra.
Anesthesia takes place in about fifteen minutes, and is usually
very satisfactory and sufficient for any operation upon the organ. It
has been especially recommended for circumcision as a substitute
for the direct method of infiltration, on the ground that the edematiza-
Fig. 96.-The Oberst method of cocain infiltration. A constrictor is first placed
around the root of the organ and the injection made with a very fine needle, as
described below. Oberst recommends a 1 per cent. solution of cocain, but the same
strength of novocain could also be used. (Miller.)
tion of the tissues resulting from infiltration was an objection in this
operation. The writer, however, has not found this to be the case.
Circumcision.—Solution No. 1, with an ordinary hypodermic
with fine needle, is sufficient. The skin is pulled well over the glans
and the point of incision determined. The injection is begun just
proximal to this point and a circumferential injection is made into
the skin and subcutaneous tissues around the organ. If the prepuce
is well relaxed and can be freely retracted, a finger is passed up on its
inner surface between it and the glans. The needle is now directed
down through the already anesthetized parts on the surface toward

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 37I
this point, injecting as it is advanced, until it reaches a point on the
inner surface of the prepuce just back of the cervix (neck of the glans).
A station is produced here, the prepuce now retracted, and, beginning
at this anesthetized point, a collar of anesthesia is created around the
glans, carrying it well around into the frenum; or, instead of the
above, the prepuce can be reflected and the anesthesia started from an
injection made from the inner surface. Anesthesia will now be com-
plete and the operation can be performed. A small stationer's elastic
should first be applied as a constrictor around the organ near its
base. In the event that the prepuce is very tight and cannot be re-
tracted, it may be filled with a I per cent. solution and held for a few
minutes, or the injection can be carried forward toward the constricted
Fig. 97.-Anesthetizing dorsal surface of foreskin from periphery toward base.
(From Braun.)
opening and this anesthetized and divided sufficiently to permit
retraction, when its inner surface can be anesthetized; or the pro-
cedure as illustrated in Fig. 97 may be carried out.
The Urethra.-Two or 3 drams of I or 2 per cent. novocain solution
and I or 2 drops of adrenalin held in the urethra for five or ten min-
utes will anesthetize the mucosa sufficiently to permit a painless in-
ternal urethrotomy or the gradual dilatation of a stricture, but will not
permit divulsion (which, however, is now rarely practised), as it does
not anesthetize the submucous and periurethral tissues. Stronger
Solutions than I or 2 per cent. are never necessary here. The same
effects can be obtained with the weaker solutions if retained slightly
longer. The urethra absorbs very actively, and many cases of poison-
ing, at times fatal, have been reported from the injudicious use of

372 LOCAL ANESTHESIA
strong solutions; consequently, one should never be tempted by haste
to exceed the safe limits.
The use of adrenalin solution when retained a few minutes in the
urethra is often of great advantage, particularly in inflamed or con-
gested conditions; the relaxation following the congestion will often
permit the easy passage of an instrument which would seem impossible
or very difficult without its use. Strictures which have been congested
following alcoholic indulgence, causing acute retention of urine, can
often be sufficiently relieved in this way to permit the passage of a
Fig. 98.-Line of infiltration for external urethrotomy.
small catheter when an external urethrotomy would otherwise have
seemed indicated.
The Meatus.--To anesthetize the meatus a very satisfactory
method is to dip the end of a moistened sterile probe into a bottle
of cocain or novocain crystals, when a few of the crystals will adhere
to the end and can be conveniently deposited in the meatus. In a
few minutes this will have produced sufficient anesthesia to permit
fairly considerable dilatation for the passage of a sound through a tight
meatus, and will also permit a limited meatotomy. But it is better
for the latter to infiltrate the meatus in the line of the proposed inci-
sion with a few drops of solution No. 1.


GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 373
The female urethra is easily anesthetized by a few drops of 5 or
Io per cent. novocain on a film of cotton wrapped around an applicator,
and passed into the urethra for a few minutes.
External urethrotomy in the ordinary case is quite easily performed
under local anesthesia. In the presence of extensive urinary infiltra-
tion it may prove difficult and test the ability of any but an ex-
perienced operator under local measures, as the fibrous tissue encoun-
tered under these conditions is difficult of thorough infiltration.
If the strictured point is deeply situated the pudic and pudendal
nerves had best be blocked, though it is possible to proceed entirely
with infiltration, which is the method preferred.
The urethra is first anesthetized, a sound passed, and the stric-
tured point located or a guide or filiform passed through it. Infil-
tration is commenced in the middle line (Fig. 98), just proximal to
the stricture, and carried well down into the subcutaneous tissues.
These are now divided, infiltrating further as we advance, until the
urethra is reached, when a little solution injected periurethrally
around the strictured point will permit its painless division or resec-
tion, if not too extensive, with subsequent approximation and suture
of the divided ends of the urethra.
The following history of a patient operated on by the author
illustrates a procedure which may sometimes prove useful:
Mr. A., aged forty-three, alcoholic, with chronic endocarditis and history of renal
disease, presented himself, with a large infiltrated scrotum with urinary fistula on inner
side through which urine and pus dribbled, only a few drops appearing at the meatus
during efforts at urination. It was found impossible to pass a sound or filiform through
the tortuous fibrous urethra. Through infiltration of the tissues at the base of the scrotum
an incision was made down to about the position of the urethra, but it was found im-
possible to readily identify this structure. The wound was packed and suprapubic cys-
totomy done, liberating a large amount of foul urine. In the Trendelenburg position
(to dilate the bladder with air) the internal urethral orifice was readily seen, and a small
Poges silk-woven catheter passed forward along the urethra. This caused no discomfort.
At a distance of about 3 inches the point of the catheter was arrested. While it was held
in this position by an assistant we returned ,to the perineal wound. Some additional
infiltration was found necessary here, as the parts had become sensitive. The urethra was
now readily recognized in a mass of fibrous tissue by manipulation of the catheter and
opened. The anterior portion of the urethra was easily followed and several strictures
divided under infiltration. -
The case made an uneventful recovery. The urinary fistula on
the side of the scrotum closed without any special treatment. Subse-
quent examination of the urine showed albumin and granular casts.
This case would certainly have been a dangerous risk with general
anesthesia. Spinal analgesia could, however, have been employed,
374 LOCAL ANESTHESIA
but we resort to the latter only when local and regional methods are
impracticable.
Epispadias and hypospadias, or other plastic operations, are usu-
ally quite easily performed under local anesthesia, but should not be
done under infiltration. Instead, the regional method of blocking the
nerves of the root of the organ as already mentioned should be em-
ployed; when extensive, always combining the operation with an ex-
ternal urethrotomy.
SCROTUM
All operations upon the scrotum can be performed under infiltra-
tion. Where resections are to be done, as in the case of superficial
Fig. 99–Method of surrounding penis and scrotum with zone of anesthesia for opera-
tions upon scrotum. (From Braun.)
*
growths or for elephantiasis, a zone of anesthesia should be created
around the part to be excised. If it involves the entire organ, infiltra-
tion should be done around the base (Figs. 99 and Ioo). If the opera-
tion involves the contents of the scrotum, the cord should be exposed
just below the spine of the pubis on one or both sides, as the case may
require, and blocked there. The genitocrural nerve lies at the back of
the cord, near the vas (Figs. 93 and IoI). By infiltrating the cord
freely in this position the nerve is reached; it is not necessary to directly

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 375
expose it. In making an injection here care should be taken not to
enter any of the large veins which may be found in this region. Make
the injection only when advancing or withdrawing the needle, not
when the needle is stationary, unless the parts are plainly in view.
The following case, operated on by Prof. Matas, illustrates the
possibilities here:
“An adult negro laborer was admitted in my service in the Charity Hospital two years
ago for the removal of an immense scrotal tumor, which extended from the pubes to the
knee. After making a linear infiltration, 13 inches in length, in the vertical axis of the
tumor, we reached a hermial sac which contained the cecum and a long appendix vermi-
formis. The hermial region was anesthetized. The appendix was removed, the sac
º
- 2
--
Fig. Ioo.—Method of injecting posterior surface of scrotum. (From Braun.)
excised, and the hermial canal closed by a Bassini operation. The dissection was then
continued, and two enormous polycystic masses (originally hydroceles of the cord and
tunica vaginalis), containing over 3 pints of fluid, were tapped and excised with the testis,
which was incorporated in their walls. The patient never complained during this long and
tedious procedure, and enjoyed a hearty meal shortly after returning to the ward. He
made a perfectly uneventful recovery.”
Operations Upon the Scrotal Contents.-Varicocele, hydrocele,
castration, etc., can all be done following a uniform method of anes-
thesia. For typical operations this is as follows: The skin on the
anterior surface is infiltrated longitudinally for about 3 or 4 inches
(Fig. 95). If the operation is for varicocele or for an orchidectomy,

376 LOCAL ANESTHESIA
the upper end of this line should begin at the spine of the pubis; if
for hydrocele, it may be lower, and the lower end reach well over the
surface of the tumor, but the upper end must reach sufficiently high
to permit ready access to the cord above. The cord is now picked up
through the scrotal wall with the finger, and the small needle passed
through the anesthetized area at its upper end and an injection made
on each side of the cord (Fig. IoI) in close contact with it; some opera-
tors inject within the cord in this way, but I find it better not to do so,
as a vein might be injured, and, while of no consequence, it might
produce a hematoma or discolor the field with blood, and as the
Fig. IoI.-Method of infiltrating around spermatic cord.
cord is to be later exposed nothing is gained. The incision is then made
through the anesthetized skin and fascia down to the cremasteric
fascia; this is divided and the cord freely exposed and drawn out of
the wound; the deep injections previously made around the cord
permit this manipulation without discomfort. With the cord now
freely exposed out of the wound it can be thoroughly injected with the
small syringe; the genitocrural nerve lies at the back of the cord near
the vas, but all veins should also have a wall of anesthesia around them,
as they are sensitive. These injections are all made high up at the
proximal end of the field. Having completed this procedure, the

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 377
entire Scrotal contents are anesthetic, and any contemplated opera-
tion can be performed. The testicle can be drawn out of the scrotum
and freely exposed to view, but traction should not be made upon
the upper end of the cord, as this pulls upon the unanesthetized parts
above and will produce pain.
If the condition is one of varicocele, the veins of the entire cord and
about the epididymis can be resected.
If for hydrocele, the inversion operation or the removal of the
parietal portion of the tunic, as in the Volkmann operation, can be
performed with equal satisfaction.
In the event of inflammation creating adhesions within the scrotum,
these may have to be infiltrated before the sac can be dissected away
freely, particularly about the septum, for here nerve-filaments cross
over from the other side.
In operations for hydrocele it has been suggested that the tunica
vaginalis be filled for a few minutes with a 1 per cent. solution of novo-
Cain, after first drawing off its contents. This, however, is not neces-
Sary if the cord has been properly blocked, as the entire parts are anes-
thetized. This procedure may, however, be done through a cannula
for the injection of irritating substances like iodin, but is hardly neces-
Sary for carbolic acid if the sac is first thoroughly emptied.
CHANCROIDS
The topical application of cocain or other agents except carbolic
acid, even in very strong solutions, for the purpose of producing anes-
thesia to permit the painless cauterization of these lesions, is quite
unsatisfactory, even for the use of nitric acid, the anesthetic effect
of the agent not penetrating deep enough. A satisfactory method of
treating these lesions is to first dry them thoroughly and then to
apply pure carbolic acid. This rarely causes any complaint or, if so,
too trifling to be of consequence. If a more thorough cauterization
than that produced by carbolic acid is desired, nitric acid can now be
added, when its action will be found painless. In using either of these
agents this way care should be taken not to permit them to run over
the skin of the surrounding parts. If the lesion is very superficial,
this can be prevented by surrounding it with a smear of vaselin.
Cataphoresis can be made use of for carrying anesthetic drugs into
the tissues in such lesions as chancroids. The objection to the method
is the time necessary for the agent to penetrate to sufficient depth to
produce satisfactory operative anesthesia. It is, however, neverthe-
less possible.
378 LOCAL ANESTHESIA
A pledget of cotton Saturated with a Io per cent. Solution of the
agent to be employed is placed over the lesion. The positive elec-
trode is placed over this and the negative at some nearby part of the
body. A mild galvanic current is used, when after about fifteen to
twenty minutes, sometimes longer, it will be found that the anesthetic
has penetrated to a sufficient depth to permit the painless use of the
galvano- or thermocautery. The time consumed in this process
renders it impracticable for the busy practitioner. A more satisfac-
tory method is the following: When the lesion is situated upon any
part of the foreskin the surrounding parts are well cleansed; a fine
needle fitted to a syringeful of solution No. 1 is entered some little
distance from the lesion, after first touching the skin at this point
with tincture of iodin. As the needle is advanced the solution is in-
jected until the surface beneath the lesion is reached, when the entire
underlying subcutaneous tissue is infiltrated. This can be facilitated
by sliding the skin toward the needle, if it is found that this will not
reach far enough, rather than make several punctures with the needle,
which may carry infection down with it. To replenish the syringe the
needle is left in the tissues and the syringe unscrewed, refilled, and
fitted on again. After thorough infiltration the actual cautery can be
used. Where the lesion is too large, where there are several in different
parts, or where they are situated upon the glans, the method of nerve-
blocking, as previously described, had better be employed.
THE BLADDER
The fundus of the normal bladder is almost insensitive to pain.
The base and neck are quite sensitive, but when inflamed even the
fundus may become sensitive. According to Lennander, the pain
caused by the overdistention of the normal bladder is due to the
stretching of its peritoneal covering. Traction upon the bladder wall
will cause pain. Any pain induced when operating upon the blad-
der, even at the fundus, is always referred to its neck, the urethra, and
head of the penis. Certain manipulations may sometimes produce
an urgent desire to urinate, although the bladder may be open and
empty. In the uninflamed bladder such operations as lithotrity or
suprapubic cystotomy for the removal of stones or pedunculated
growths is quite easily carried out under local anesthesia. But in
the acutely inflamed or old chronically inflamed and contracted blad-
der such operations may give some difficulty and will have to be
handled gently under such methods as infiltration and topical appli-
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 379
cations, and had best be operated by regional methods. (See Para-
Sacral, Epidural, and Spinal Anesthesia.)
Suprapubic cystotomy is always done by us under local anes-
thesia as a preliminary step to suprapubic prostatectomy in infected
bladders, when, after a few days’ free drainage and mild irrigations,
allowing the cystitis to clear up, the organ is removed by a few minutes'
narcosis under nitrous oxid or ether or may be removed under local
anesthesia. By this plan, which stops the trying tenesmus and
frequent efforts at urination so distressing to those patients, which
prevents their rest and ability to properly nourish, they are now given
a few nights’ uninterrupted sleep, which greatly revives old and
feeble patients, when the operation can be safely concluded, which
would most likely result fatally if attempted at one sitting.
Antipyrin was formerly much used as a vesical anesthetic, due to
its possessing styptic and mild antiseptic properties, but since the
advent of adrenalin it is now rarely used.
In the normal bladder the power of absorption is very limited, but
much more active in the urethra. In the acutely inflamed bladder
this power is much increased, and is always more active at the base.
To anesthetize the bladder it is necessary to use only very mild
solutions. Many cases of poisoning, often fatal, have resulted from
the injudicious use of too strong Solutions.
Solution of cocain (o.25 per cent.) or solution of novocain (o.5o per
cent.) and a few drops of adrenalin is sufficient, using 2 or 3 oz. of
this solution, either passed in by pressure through the urethra or by a
catheter, after first well cleansing the organ to remove all mucus,
pus, or blood-clots.
If the bladder is very irritable, and efforts at urination are excited
with expulsion of the solution, only a few drams are passed in at once,
when after a few minutes' delay, allowing time for some effect to be
produced, a little more is added, until the desired quantity is intro-
duced.
To anesthetize the neck of the bladder for the practice of cystos-
copy, etc., it is more convenient to use Small tablets of alypin or
novocain containing from 3 to I gr., which are deposited at the de-
sired point by specially constructed depositors made for this purpose
(Fig. Io2). After using any anesthetic, either solution or tablet, it is
necessary to wait from ten to fifteen minutes for the full effect to be
felt.
Suprapubic Cystotomy.—When done for drainage, it is ordinarily
unnecessary to anesthetize the interior of the bladder, unless it is
38o LOCAL ANESTHESIA
very sensitive or inflamed, but it should be moderately distended with
water to bring the fundus well up to the suprapubic space. When
found irritable the anesthetic can be added to the solution. When
the operation contemplates the use of retractors or other instruments
within the bladder cavity, as for the removal of pedunculated growths,
or thorough direct vesical inspection, then the bladder should first be
anesthetized. -
Operation.—The skin and subcutaneous tissues in the middle line
just above the pubes (Fig. 95) are infiltrated and a few drams of solu-
tion directed down between the recti muscles. The tissues are then
Fig. Ioz.—Bransford Lewis depositor (slightly reduced in size) for depositing anes-
thetic tablets at neck of bladder and in posterior urethra. The curved figure with the
round end is the obturator; the other has a flat end and is intended to push the tablet
home after obturator has been withdrawn and tablet dropped into lumen of cannula.
divided and the recti muscles retracted. More solution should now be
injected into the perivesical space, and the fat and peritoneum pushed
up out of harm's way when the fundus of the bladder is recognized
by the large veins coursing over its surface. This is caught with
tractors; if found sensitive a superficial injection is made into the
walls with a fine needle. The mucous membrane at this point is
usually not sensitive, or if so the injection made into the walls suf-
fices to control it. The bladder may now be opened.
In operating upon the interior of the bladder the Trendelenburg
position will be found highly useful. In this position, with long narrow

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 3 8I
retractors, one on each side, passed well down into the bladder, the
upper wall of the bladder ascends under the pressure of the air which
enters, thus freely opening the vesical cavity. A few sponges will
remove the remaining fluid.
A very Satisfactory method for the thorough direct visual examina-
tion of the bladder is to use a short proctoscope, with light on the end,
passed into the cavity in the Trendelenburg position. This permits
examination with far greater facility and accuracy than is possible
with any cystoscope.
All of the above procedures are quite satisfactorily carried out
under local anesthesia.
If a pedunculated or well-defined superficially situated growth is
to be removed its base and surrounding mucosa is first infiltrated with
Solution No. 1, when we can proceed with the operation the same as
with general anesthesia. -
Sections of the fundus or posterior walls can be easily removed by
infiltrating around the area to be excised, always leaving a catheter,
preferably a Pezzer, in the bladder when finished. -
After opening the bladder, if the base and walls are found sensitive,
a few pledgets of cotton, soaked with 2 per cent. Solution of novocain
adrenalin, placed in contact with these parts for a few minutes, will
usually suffice, or swabs may be used with stronger (Io to 20 per cent.)
Solutions in the same way as they are used in nose and throat work.
PROSTATECTOMY 1
In the operative relief of hypertrophy of the prostate, we have
in the great majority of cases to consider certain factors which are not,
as a rule, involved in other surgical procedures, namely, that of age,
as most of the cases requiring surgical relief for this condition have
reached or passed middle age, and many of them are infirm or weak-
ened by suffering and infection.
In the old and feeble prostatectomy is a formidable operation,
though not attended by a greater mortality than that following any
other major operation in the same class of patients. However, it
may even show a more favorable comparison by observing certain
methods in the handling of these cases.
Surgical technic has reached such a stage of perfection that in
the more commonly performed operations it would seem difficult to
suggest improvements in the recognized methods of procedure in
typical cases. Improvements will come, but I believe that they will
*From a paper read by the author before Louisiana State Med. Soc., 1913.
382 LOCAL ANESTHESIA
be more in the preparatory treatment, general handling of the case, and
refinement in details, rather than in the general principles involved
in the operation.
One of the refinements of detail, recently introduced as a general
surgical procedure, is the anoci-association of Crile; this, I believe, to
be a factor of great consequence, particularly when applied in old and
feeble patients, as it prevents shock-producing impressions from the
field of operation from reaching the higher nerve-centers.
The two great factors in the production of shock are trauma and
hemorrhage. Surgical trauma we cannot prevent, as we intentionally
inflict it, but we lessen its shock-producing effect by blocking all nerve-
endings in the field, by injecting the tissues with weak anesthetic solu-
tions; this is done whether the patient is to have a general anesthetic
or not, as Crile has shown that general anesthesia does not prevent
shock from trauma. The method which I wish to present to-day is
the result of a gradual evolution in handling cases of prostatectomy.
While I had never noticed any marked shock following prostatectomy
by former methods, in those cases in which I used the anoci-associa-
tion of Crile, by resorting to a preliminary injection of the prostate
with anesthetic solutions, there was an improvement, as these cases
showed practically no change in their physical condition after opera-
tion. -
The control of hemorrhage was accomplished by the logical addi-
tion of adrenalin to the injected solution; the absence of all bleeding in
cases so treated was most striking, practically no blood being lost at
all, just enough to moisten a few sponges, thus there was a decided
gain for the patient—the two shock-producing factors eliminated.
The results of this technic were borne out by a more rapid conva-
lescence of these patients, and this method, combined with a two-stage
operation opening the bladder a few days before under local anesthesia,
has enabled me to carry to a successful termination cases of badly
infected bladders in feeble patients which I would have hesitated
to operate by any other method.
The continued use of the above method and its gradual extension
led to the elimination of general anesthesia, until now it is used only
from choice and not from necessity, as these cases can be as suc-
cessfully operated by local anesthesia as can hernia, rectal, and many
other conditions.
The technic of the procedure is as follows:
One hour before operation a suppository, containing Io gr. of anes-
thesia, is placed in the rectum to anesthetize this region and prevent
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 3 8 3
any discomfort when the finger is introduced here in elevating the
prostate.
About the same time, one hour before operation, a hypodermic of
morphin, ; gr., and Scopolamin, Tºº gr., is administered to lessen
psychical disturbances. The operation is begun by opening the blad-
der under local anesthesia; its walls are then retracted by long, deep,
narrow retractors, bringing into view the field of the prostate. De-
Fig. Io9.—Author’s method for injecting prostate: Lines 1–3 indicate points for
injection above and on side of prostate; 4, beneath prostate, this may at times be
more conveniently made by a curved needle; 5, enters urethral opening, penetrates
urethra, and is made between lobes of gland. While the lines show the axis of the
injections with the prostate lying normally in its bed when the injections are made, the
prostate is lifted up by a finger in the rectum, so that the needle can be more readily
entered in the proper position through the suprapubic opening.
pending upon the size and shape of the prostate, several points are
selected for injection on the vesical surface, usually one below the
opening of the urethra near the base of the gland and one on either
side. The needle is passed through the mucosa with the idea of mak-
ing the injection between the true and false sheath of the prostate,
as it is in this plane that the solution must diffuse around the gland,
and it is in this plane that its enucleation is effected; it is here where
+

384 LOCAL ANESTHESIA
the large venous plexuses are situated and where the nerve filaments
are more easily reached as they pass through to the prostate.
Two or 3 drams of a o.5o per cent. novocain Solution, containing
15 min. of adrenalin to the ounce, are injected at each of the above
points. The needle is then passed into the urethral opening, and the
lateral wall pierced first on one side and then on the other, and
similar injections made at these points (Fig. Io9).
If the gland is very large, or there is much of a projection above
the urethral opening, an additional injection can be made here, other-
wise the above will prove sufficient. It is well now to wait two or three
minutes for the solution to diffuse and through anesthesia to be estab-
lished before beginning the enucleation. While waiting for the Solu-
tion to diffuse the action of the adrenalin is observed in the prostate,
which becomes quite pale and bloodless.
In making the injections, should they be made into the substance
of the gland itself, no harm will be done, only they are not quite as
effective as when injected peripherally between the true and false
sheath; any excess of the solution thrown into the gland in this way is
removed during its enucleation and not absorbed.
This method may not appeal to all of my audience, as it requires a
certain familiarity with local anesthesia before one cares to undertake
major operations by its use alone. - -
I will, nevertheless, urge that even under general anesthesia you
resort to the preliminary injection of the field with a local anesthetic,
combined with adrenalin, as a most potent agent in the elimination of
those two most active factors in the production of shock—trauma and
hemorrhage.
Dr. Tinker (“Jour. Amer. Med. Assoc.,” Feb. II, 1905) reports a
perineal prostatectomy by first blocking the pudic nerves and using
infiltration on the skin and deep parts.
Prostatic abscesses, when pointing toward the perineum, can be
opened under infiltration. With the finger in the rectum as a guide,
the infiltration and dissection is advanced until the abscess is reached.
It is hardly necessary to block the pudic nerves, unless the abscess is
very deeply situated.
A particularly favorable method of operating upon these parts is
by parasacral anesthesia, as described under that heading.
ANORECTAL REGION
Any of the many affections involving the easily accessible parts
of this region may be quite satisfactorily operated upon by local
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 385
anesthesia, provided the procedure is not too complicated; where this
is the case, as in extirpation of the rectum, parasacral anesthesia should
be resorted to.
The region of distribution of the pubic nerve may, in many re-
Spects, be compared to that of the fifth nerve, the two most sensitive
areas in the body. The disturbances arising from disease of these
parts are often considerable and out of all proportion to the size of the
lesion if situated elsewhere; their reflexes are numerous and varied,
and often involve remote parts of the body.
In the rectum the sensitive area is practically limited to the
terminal 2 inches of the bowel or anal canal. Above this point
there is very little Sensation. It is in this terminal 2 inches that
disease is most frequently encountered—in fact, more often than in all
the rest of the alimentary canal. When we consider the nature of
these affections, we are forced to the conclusion that the great majority
of them may be claimed by the domain of local anesthesia, reserving a
few of the more serious operations, such as extensive resections, for
general narcosis; these, however, are a small percentage of the opera-
tions performed in this region. Persons affected with anorectal dis-
ease are, as a rule, more nervous and apprehensive, and for this reason
the preliminary hypodermic of morphin, # gr., Scopolamin, T40 gr.,
recommended elsewhere for all major operations, should not be omitted
here.
All operations under local anesthesia in this highly sensitive
region have to be performed with great care, and the technic of any
method of anesthesia employed carried out with exactness and thor-
oughness to insure success; the solutions need not be of any greater
strength than those used elsewhere (o.25 per cent. novocain for infil-
tration and o.50 per cent for nerve blocking, with the addition of the
usual amount of adrenalin), though stronger solutions may sometimes
be necessary.
Reclus, in 1889, was the first to satisfactorily anesthetize this
region to permit the painless dilatation of the anus. He used I to
2 per cent. solutions of cocain. He was followed by Scleich in 1894,
and the methods of infiltration used in this region to-day are largely
the same as those advocated by these two pioneers in the field of
local anesthesia.
The nerves of this region are practically the same as those described
for the genito-urinary organs, and, when preferred, the pudic nerve
can be blocked in the same way near the spine of the ischium (Fig.
IoA), and if the operative field extends some distance behind and to the
25
386 LOCAL ANESTHESIA
side of the rectum, as in fistula, the inferior pudendal will also have
to be blocked on the outer side of the ischium; both procedures are
discussed under the above heading. When used, this method should
be combined with a thorough perianal infiltration in the same way as
described later.
This procedure, while used by some operators, is not very popular,
as it often fails to produce a satisfactory surgical anesthesia, due to
the uncertainty of accurately reaching the nerve at the point of in-
jection. -
Fig. Ioa.—Method of making paraneural injection around pudic nerve. The long
needle is entered at an anesthetized point about 1% inches back of rectum. The finger
in the rectum locates the spine of the ischium and guides the advancing needle. The
injection is slowly made as the needle is advanced to about $ inch to the inner side and
slightly in front of the base of the tuberosity of the ischium.
The following method is much to be preferred, being simpler,
quickly executed, and absolutely reliable in producing a perfect sur-
gical anesthesia.
This technic is so simple and quickly executed that the writer al-
most invariably uses it for all operations in this region (hemorrhoids,
fissure, prolapse, etc.) in preference to a general anesthesia.
The tissues are first infiltrated subcutaneously around the anus at
the mucocutaneous junction, as seen in Fig. Ios. It is better to
start the injection an inch or more away in the less sensitive skin, and
advance toward this region, when the injection is then carried out cir-

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC oper ATIONs 387
cumferentially, rather than to make the first puncture in this area,
which is highly sensitive, and will always excite some complaint, and
in nervous patients cause them to become uneasy and lose confidence
in the promise of a painless operation. The author always uses an
ethylchlorid spray on the skin at the point of puncture, first thoroughly
protecting the anus against any contact with the spray by holding a
gauze sponge well against it.
- T
Fig. IoS.–Points of injection for surrounding anal canal with zone of anesthesia.
(From Braun.)
The circumferential injection is made subcutaneously, as the
skin and mucous membrane at their point of junction are very thin,
and an intradermal injection difficult and not at all essential.
By drawing out the skin of this region with one hand the tissues
are put upon the stretch, and all folds and creases obliterated (Fig.
Io9), making it less likely to transfix a fold causing pain; the solution
is injected as the needle is advanced; for each re-insertion of the needle
starting just back of the point where the needle last stopped; having
completed the circumferential injection, a finger is now passed within
the rectum as a guide, and the large syringe and long needle used; the

LOCAL ANESTHESIA
Fig. 106.-Method of making subcutaneous injection around anus. Patient in Sims'
position.
Fig. IoT.—Method of making deep perirectal injections.
needle is passed through the anesthetized area of skin and directed
up the bowel, just outside of the sphincters, injecting, as the needle
is advanced, to a depth of about 2% or 3 inches (Fig. 107); four points


GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 389
are injected: one on each side, injecting in each of these about 1o c.c.,
and one in front and behind the bowel, injecting in each of these about
5 C.C.
Fig. IoS.–Schematic representation of method of producing anesthesia of anal canal
—taken from Braun, slightly modified.
Anesthesia results almost immediately, at most after a delay of a
few minutes, when dilatation may be begun and can be as thoroughly
carried out as under a general anesthetic.
Fig. ico-Method of dilating rectum with hand in cone shape.
A graphic illustration of the method of making these injections
is shown in Fig. IoS. The author always prefers to use the hand as a
dilating medium, which is less likely to tear or lacerate the parts,


390 LOCAL ANESTHESIA
using soap as the lubricating medium; first one finger is passed, then
two and three, and, finally, the whole hand in a cone-shape is rotated
around in a screw-like fashion (Fig. Io9) until dilatation is complete.
This is the method always used by Prof. Matas for dilatation and is
superior to any other.
In operations for fistula, in addition to the above method of anes-
thesia, which anesthetizes the anal canal and permits dilatation, the
fistulous tract must also be anesthetized by injections made on each
side and beneath it, so as to thoroughly embrace it within a wall of
anesthesia. The method of making these injections is illustrated in
Fig. 110–Method of anesthetizing fistulous tract. (From Braun.)
Fig. IIo. The fistulous tract can then be slit up, excised, or curetted
as preferred.
For methods of infiltration it is well to precede the injections in
badly inflamed or sensitive cases by placing a pledget of cotton
saturated with 5 or lo per cent. novocain solution within the anal
canal, and allow it to remain while injecting elsewhere; in this way the
canal will permit the painless introduction of the finger to guide the
needle in the deep infiltration.
In the original method, first advocated by Reclus and Schleich,
the infiltration was made directly into the substance of the sphincters,
but this is not necessary, and it would seem advisable to infiltrate the

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONs 391
loose cellular tissue surrounding the bowel rather than the muscle
itself. When the above technic has been well carried out it is not
necessary to infiltrate the mucosa; this is then, consequently, a para-
neural regional anesthesia. By the above technic any of the ordinary
operative procedures for hemorrhoids, fistula, polypi, ulcers, fissure,
or resection of the rectal mucosa for prolapse may be quite satisfactorily
and painlessly performed. In many operations upon this region it is
not necessary to dilate the Sphincter. While this is desirable in all
operations of any magnitude to paralyze the muscles and permit
free inspection and access to the anal canal, there are many cases of
Sentinel piles and other Superficially situated lesions, as fissures, where
this practice may be dispensed with and the lesions dealt with by simple
infiltration. This is particularly suited to office practice, where many
of the minor affections of these parts may be operated upon.
In operations for fissure, while it is always desirable to stretch the
Sphincter, this procedure alone often sufficing for a cure in super-
ficial lesions, it is not absolutely necessary. With the proper care and
delicacy in manipulation these cases can often be operated in the
office or at the patient’s home with satisfactory results. The needle
is entered in healthy tissue, just below the lesion, and infiltration
gently carried out, advancing the needle under the fissure in the
Substance of the sphincter, infiltrating gently as it is advanced, until
the entire underlying area is well infiltrated; the finger will then be
quite easily tolerated in the rectum, and the extent of the lesion well
explored.
A blunt-pointed bistoury is now advanced on the flat against the
finger until the upper part of the area is reached, then turned edge
down, and the fibers of the sphincter at the base of the fissure incised
to a depth of about # inch. This may be done at one point in the
middle or on each side, and effectually puts the muscle-fiber at rest
and permits the ulcer to heal; it is then dressed with ichthyol and
anesthesin ointment, I 5 or 20 per cent. of each.
In performing the operation this way, care should be exercised
not to incise too far up the bowel or too deeply for fear of opening
some Small artery, which may give rise to an unpleasant hemorrhage;
it is only in that portion of the canal surrounded by the external
sphincter that the incision should be made; more extensive ulcerations,
extending up the bowel, should not be treated this way. Malignant
disease of these parts unless quite limited, superficially situated, and of
easy access should be reserved for parasacral, spinal, or general anes-
thesia. Perirectal and ischiorectal abscess if superficial may be easily
392 LOCAL ANESTHESIA
opened by infiltration. In the case of the former, where it is desirable
to dilate or divide the sphincter; one of the above-mentioned methods
should be used to secure anesthesia.
The use of sterile water as an anesthetic agent when injected
into the tissues has long been known, and its application to surgery
of these parts has frequently been tested; Dr. S. G. Gant, of New York,
is particularly enthusiastic in its use, and has done much to popularize
it here. For hemorrhoids or fistula operations of limited extent the
anesthesia is quite satisfactory, but it is not suited for extensive opera-
tions where the deep parts are involved. The objection to its use is
the burning pain produced by the infiltration; this, while greater in
some cases than others, is often quite Severe, and is not a negligible
factor in considering this form of anesthesia. The pain in making
these injections is much lessened if the injection is very slowly made, so
as not to distend the tissues too rapidly; by the addition of a small
quantity of cocain or novocain, ſº per cent., this infiltration pain is
entirely relieved; this, however, is no longer pure-water anesthesia.
For a further consideration of water anesthesia (anesthesia dolorosa),
see chapter on this subject.
The use of ethyl chlorid about the anus is rather unsatisfactory,
as it often produces considerable burning, but for superficial incisions
in areas removed from the anal margin, or where this can be protected,
it is often quite satisfactory. -
Before dismissing this subject reference should be made to the use
of quinin and urea, which are applicable for the surgical treatment of a
limited number of rectal affections, and the reader is referred to the
chapter on this subject.
The topical application of the various analgesic and anesthetic
preparations is often of great value here for the palliative relief of the
inflammatory affections of these parts, such as hemorrhoids, fissures,
ulcers, etc. Anesthesin has largely replaced the use of antipyrin and
orthoform, as it is a more active agent, and, in view of its slow solu-
bility, maintains this action for a long time; it is also practically non-
toxic, even in concentrated solutions (IO to 15 gr, can be safely admin-
istered internally at a time). It is best used in ointment form in
Io and 20 per cent. strengths. Combined with other astringent and
sedative drugs (adrenalin, hemamelis, belladonna, etc.), in this form
its application externally or to the anal canal with a pile-pipe or by
suppository often affords gratifying relief in many painful affections.
Cocain, novocain, alypin, etc., when used in a similar way, have to
be frequently repeated, and may prove dangerous from their rapid solu-
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 393
bility if used in concentration or, if long continued, may encourage a
habit, and for these reasons are rarely employed in this way.
Operative procedure under the topical application of pure carbolic
acid, while practical for limited procedures involving nothing more
than a Superficial incision, is rather unsurgical, and is not to be recom-
mended for more than an incision such as would be needed for turning
out the clot in a thrombotic hemorrhoid or opening a superficial ab-
Scess; it can also be made use of for anesthetizing a small point to
permit the painless introduction of the hypodermic needle. When
used for anesthesia the surface upon which it is applied should be
perfectly dry, and after allowing it to remain a few minutes the
excess is wiped off.
As a postoperative application the topical use of one or more of
the various sedative and analgesic preparations is often of great value
in allaying the after-pain and burning common to most operations
upon these parts, particularly hemorrhoids, where the cautery has
been used. Dr. James P. Tuttle claims for sodium bicarbonate a
Sedative action Superior to anything else; he says for this purpose it is
incomparable; it has no analgesic action under other conditions.
Following other operations the immediate free use as a primary dress-
ing of a Io or 15 per cent. ointment of anesthesin or orthoform will
be found to greatly lessen the postoperative discomfort as the anes-
thesia passes off.
For the non-operative or palliative treatment of chronic tubercu-
lous, syphilitic, or cancerous ulcers, anesthesin, orthoform, or carbolic
acid in ointment form prove effective analgesic applications. A
quite satisfactory treatment for fissures, one of the most painful of
rectal conditions, is by tampons soaked in ichthyol and freely sprinkled
with anesthesin, such applications giving relief often for many hours;
the same may be said of quinin and urea used in ointment form.
Much of the after-pain from rectal operations is due to spasm of
the sphincters, and when opiates are used for this purpose it may take
unsafe doses to control it; better agents are chloral and bromids
(per orem), which are often more effective and safer, used in conjunc-
tion with an anesthesin ointment. For the chronic aching or neuralgic
pain of this region a satisfactory combination is antipyrin, acetanilid,
and codein administered internally.
GYNECOLOGIC OPERATIONS
The surgery of the female generative organs forms a large part of
the operative work of the present time. Much of this work on the
394 LOCAL ANESTHESIA
external and readily accessible parts may be quite easily and satis-
factorily performed under local methods of anesthesia, and even some
of the more complicated procedures on the deeper parts may, with skill
and gentleness, be painlessly, or almost painlessly, accomplished in
suitable subjects.
Women, as a rule, are more apprehensive and fearful than men, and
often so extremely nervous, particularly when having suffered long
anococcygeal nerves
anororºgeal lºg.
r Levator and
-
Sphincter an externus, Glutaeus maximus x
pudir nerve
- ºnfrºnal pudºr art
- Internal nudit rein
ºnf haemorrhoidal and perinear
lºt infr- narrºs
a 'rhuneul nerve
medial inferior cuneaſ nerve.
inſerior haemorrhoidal artery -
internal pudiº vessel
Glutaeus maximus
perineal branches
> - of posterior
femoral rutaneous
erºe
perimral nerve
Transversus perimei, ---
superfinalis
- .* --
mrogenital --
trigone
*- *. art of clitoris
-
-
*.
N*.
• dorsal nerve
- º- of ritors
º º ulbus vestibuli
urethral
orifice mºn
Ischiocavernosus' posterio.”
labia/
Bulbo-
rivernostis
º
- - - - -
rferºes --
Fig. III.-The nerves and vessels of the female perineum. Upon the right side
the bulbocavernosus has been partly removed and the vestibular bulb exposed, the
transversus perinei superficialis divided, and the urogenital diaphragm incised. **=The
origin of the internal pudic vein from the vestibular bulb (vena bulbi vestibuli).
(Sobotta and McMurrich.)
from their various affections, that they make poor subjects for any
form of local anesthesia. Many prefer to take a general anesthetic,
and be treated as if they were really not there at all. It is, accord-
ingly, advisable with the timorous and fearful not to attempt any but
the simpler operations on the exposed parts by local anesthesia, re-
serving all complicated procedures for parasacral, spinal, or general

















GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 395
narcosis. However, in the presence of contra-indications to general
anesthesia, and with positive indications for operative interventions,
many of the more complicated procedures may be safely and satis-
factorily performed by the skilful use of local measures alone, or in
combination with light Superficial anesthesia for the more painful
and deeper parts. (See chapter on Combined Methods of Anesthesia.)
In nervous and sensitive patients care should be taken to always
administer one hour before operation a preliminary or preparatory
hypodermic of morphin, to # gr., with scopolamin, rºw gr., as recom-
mended in the preceding part of this volume. It is also well to have
a sympathetic nurse stand by the patient and hold her hand or en-
courage her if she is uneasy. For a consideration of the nerve-supply
of this region see Fig. III, and for description and methods of blocking
Same See Section on Genito-urinary Organs.
In all the external parts and lower 2 or 3 inches of the vaginal tract
Sensation is very acute, but the vault and upper parts of the vagina
have very little sensation. The cervix and uterus are not very sensi-
tive to incisions—volsellum, forceps, or needle punctures—but are quite
Sensitive to stretching, as in dilatation of the cervix. Also, the mucosa
of the cervix and uterine cavity has very little sensation, but will not
Stand a thorough curettage without anesthesia. The same may be
Said of the peritoneal investment of the uterus, which should not be
Operated upon without some infiltration.
Solution No. 2, § per cent. novocain, is used in all operations
upon the external parts, which are highly sensitive. Solution No. 1,
o.25 per cent., is ample for the deeper infiltrations, but if preferred
No. 2 can be used throughout.
To each solution add from 5 to Io drops of adrenalin, I: Iooo to
3 or 4 ounces, if the field is extensive and much solution will likely be
injected, using the smaller quantity of adrenalin.
The Perineum and Postvaginal Wall.—A point on the perineum
midway between the anus and vaginal outlet is anesthetic intra-
dermally; establishing here a station through which the long needle
is entered, in the event of an extensive laceration up to or including
the sphincter ani, this point can be made just within the vaginal outlet.
The long needle is entered here and passed up in the middle line,
injecting as it is advanced as far as the contemplated field of operation,
using often as much as 5 or Io c.c.; a finger can be used either in the
vagina or rectum as a guide. If the plane of tissue is quite thick it
is best to pass the needle well below the vaginal mucosa in the deeper
planes, as the solution can better diffuse in these deeper layers, but
396 LOCAL ANESTHESIA
when dealing with an extensive laceration with rectocele, where the
rectum and vaginal mucosa, are in close contact, the needle had best
be passed just beneath the vaginal mucosa, and here the finger is
kept in the bowel as a guide. By injecting the solution as the needle
is advanced, the solution separates the plane of tissues and there is
less danger of the needle puncturing the rectum.
Fig. 112.-For anesthesia of vaginal outlet, including labia majora. (From Braun.)
Having made the midline injection, the needle is partially with-
drawn and directed slightly laterally and upward on first one side
and then the other, using in each an additional 5 or Io c.c., depending
upon the extent of the field. Similarly, a third or fourth injection can
be made just lateral to the preceding, until practically the entire
vaginal canal except the roof has been infiltrated. A crescentic-like
injection, made subcutaneously with the long needle around the
vaginal outlet and carried up on each side the full extent of the field,
completes the anesthetizing process.
If a perineorrhaphy is to be done, and the tearinvolves the sphincter,
the anal canal must then be anesthetized, as described in that sec-
tion. The above method of injection gives a perfect anesthesia and
is very quickly done after a little practice, and the latter steps of the

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 397
operation, if for perineorrhaphy, much facilitated through the sepa-
ration of the different planes of tissues by the injected solution.
To Anesthetize the Entire Vaginal Outlet.—This is done by a
circumferential injection, as illustrated in Fig. 112, the lower portion
as described above. Another crescent-like injection is made from
above, which meets the lower field, starting preferably over the external
-
-
L
Fig. 113.-Area of infiltration for anterior colporrhaphy. (From Braun.)
ring of the inguinal canal on each side, making the injection fairly deep
and liberal here to thoroughly block all fibers of the ilio-inguinal and
genitocrural nerves, as they emerge from this opening to be dis-
tributed to the tissues of the labia majora.
Anterior colporrhaphy is done by pulling down the cervix with a
volsellum; at this point on the cervix a little infiltration can first be
done before applying the instrument. With the cervix well down and

398 LOCAL ANESTHESIA
on the stretch the submucous tissues between the cervix and urethral
opening are well infiltrated (Fig. II.3), carrying the infiltration well
out laterally to permit free exposure of the deep fascia in the Subse-
quent dissections.
The cervix is anesthetized by drawing it down with a volsellum
and making a free submucous infiltration around its neck, at its
junction with the vaginal vault. In making this injection in front care
should be exercised not to injure the bladder; the point of the descent
of this organ and its proximity to the vaginal vault had best be located
beforehand by a sound passed within the bladder. A long fine needle
with large syringe is now used, the needle directed up in the long axis
of the cervix on each side, just within the cervical tissues, to a depth
of from 1 to 2 inches, and about ounce of o.50 per cent. novocain in-
jected on each side, injecting as the needle is advanced.
After a few minutes this will permit a fair degree of dilatation, when
trachelorrhaphy can be done, combined with a curettage of the Cervical
canal. Curettage of the body of the uterus is not often very Satis-
factory under local anesthesia when thoroughly done, but a limited
amount is often well tolerated after the above injections, or a few
whiffs of ether can be given just at this point in the operation.
Ruge describes the method of anesthesia for a vaginal hysterec-
tomy as follows: -
“A long needle is introduced to one side of the cervix to a depth of
4 to 5 cm., being directed in a somewhat lateral direction, in order to
strike the nerve-trunks before they have undergone their ultimate
division. If the needle is introduced slowly, most vessels and any coils
of intestines with which it may come in contact will be pushed aside
and not injured. When the needle has been satisfactorily introduced,
the Io c.c. syringe is attached and the solution injected as the needle
is withdrawn. -
“The process is repeated on the opposite side, then at two points
on the anterior and two on the posterior vaginal vault injections of
3 to 5 c.c. are made. In the anterior vaginal vault it is necessary to
introduce the needle 2 to 3 cm. deep, but in the posterior just through
the mucosa.
“Vesical symptoms are controlled by using instillations to pre-
vent pulling on the viscus from being unpleasant.”
This operation has never been performed under local anesthesia
by the author, and it would seem somewhat questionable to pass a
needle in any direction in which it might perforate the bowel. If
the needle is fine and the solution injected as it is advanced the danger
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 399
of injuring the ureter or vessels at these points is very slight, and if
punctured with a fine needle no damage is likely to result, but we can-
not feel the same about the intestines. It would seem safer to the
author in doing this operation to first free the bladder from the uterus
and open the peritoneum above, as was done in the case described later,
then with a finger in the cavity the broad ligaments or their internal
attachments can be infiltrated under the guidance of the eye and finger.
Thaler, in describing the technic for the Dührssen-Bumm operation
of anterior hysterotomy, as done in Schauta's clinic for cases of pla-
centa prævia, eclampsia, etc., where rapid delivery is indicated, states
that the injection is made high up on the anterior lip of the cervix
and to the right and left of the midline, well down into submucous
tissue, about I cm.; the cervix is slit up to this point, when further
injections are made into the anterior uterine wall as the procedure
progresses. The use of adrenalin in the solution prevents hemorrhage.
The female bladder can be quite easily opened through the vagina
by infiltrating above and in front of the cervix in the middle line,
carrying the infiltration well down to the submucous tissue of the
bladder. A sound is passed into the bladder and turned point down to
present the bladder at this point; unless the bladder is inflamed or
hyperSensitive it is not necessary to anesthetize it; when necessary it
is done in the same way recommended for the male bladder. The in-
filtration of the submucous tissues over the point of incision is suffi-
cient to anesthetize the mucosa here, and its incision causes no discom-
fort.
Operations for vesicovaginal fistula, if easily accessible, can be
performed in this same way by infiltrating around the opening, the
infiltration facilitating the separation of the bladder from the vaginal
wall.
The female urethra is easily anesthetized by a film of cotton placed
around the end of a probe, and saturated with a 5 or Io per cent. Solu-
tion of novocain passed into the urethra and allowed to remain
for a few minutes.
Caruncles are easily extirpated by infiltrating around and beneath
them; a Swab with Io per cent. Solution can be used on the surface
for a few minutes at the point at which the needle is entered.
The removal of Bartholin's glands or benign growths is quite
easily performed by infiltration; also epitheliomata when superficial and
of limited extent; malignant diseases of the cervix, uterus, or deeper
parts should not be undertaken by these measures, but reserved for
parasacral, spinal, or general anesthesia.
4OO LOCAL ANESTHESIA
In operating upon the cervix and uterus, pulling down these parts
to the vaginal outlet is attended with some discomfort, and should
not be attempted where they are bound down by adhesions or fixed
in the abdominal cavity, but in cases where these parts are well relaxed
and freely movable operation can be quite satisfactorily undertaken.
Polypican also be removed in this way, or even without anesthesia,
as they have no sensation and, the division of their pedicle is without
pain. Where the parts can be well brought down, as in prolapse, the
peritoneal cavity can be easily opened in front of the uterus, its
fundus brought down, and any of the various fixation operations
performed.
The following history illustrates an extensive operation upon these
parts on a favorable subject:
Mrs. H., aged sixty-three, a stout lady with flabby and relaxed tissues, had been suffer-
ing with a complete prolapse of the uterus with marked rectocele and cystocele for the
past fifteen years, the result of extensive lacerations during the child-bearing period.
The bladder and rectum hung down from the vagina like two distended pouches, the
uterus protruding from between them, making it necessary for her to replace it before she
could sit down. She suffered the usual disturbances with the bladder and rectum as well
as the other symptoms common to this condition; her dread of an anesthetic had forced
her to tolerate these discomforts for many years. When I assured her, much to her
surprise, that she could be easily and painlessly operated on under local anesthesia she
embraced the opportunity readily.
The Operation.—The anterior vaginal wall in the midline, between the cervix and
meatus, was first infiltrated and then incised down to the bladder wall; the infiltration and
dissection was carried well out to the sides to freely separate the bladder from the surround-
ing parts; the same was done with its attachment to the uterus. The peritoneal cavity
between the bladder and uterus was then opened, and, with one finger holding up the
bladder, a long needle was used to inject a small area on the anterior surface of the uterus
to prevent any pain which might be caused by catching the organ at this point with tenacu-
lum forceps; the uterus was then secured and anteverted, so as to bring its fundus forward
into the wound in the vagina; it was held here while the bladder was pushed up well into
the cavity and behind it, and the fundus secured to the deep fascia behind the pubis;
thus firmly anchored in this position it prevented the descent of the bladder and was
itself prevented from retroverting, the first step necessary for its descent; the superficial
parts were then closed. The perineum was now dealt with by commencing at the vaginal
outlet and making a rather free submucous infiltration, extending well back in the middle
line and well out on each side. The mucous membrane was then incised from side to side
at the vaginal outlet and dissected up freely, this step being markedly facilitated by the
infiltration which separated the rectum from the vaginal mucosa and greatly lessened
the danger of opening the rectum so likely to happen in bad cases of this kind. The
muscles in the vaginal walls were next sought for, and their atropic remnants approxi-
mated in the middle line, restoring a fairly satisfactory perineum and normal vaginal
outlet. After trimming away the excess of vaginal mucosa the wound was closed. This
entire procedure was without pain and the convalescence without incident.
It is now six years since the operation was performed, During
this interval I have heard from the patient repeatedly, and she has
GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 401
remained entirely well. The infiltration method was used for the
above case instead of the regional injection of the pudic nerves, as the
infiltration greatly facilitates the separation of the different planes of
tissues in cases of this kind, and the work is more quickly and easily
done than under a general anesthesia without the aid of infiltration.
Operations upon the round ligaments in the inguinal canal for
purposes of shortening them by the Alexander method or any of its
modifications is quite easily done under infiltration, and should be
governed by the same indications as when operating under general
anesthesia, that is, the free movability of the uterus and other internal
parts.
Infiltration is first done over the external ring and along the
Course of the inguinal canal; the superficial parts are incised, and
the external ring and aponeurosis of the external oblique exposed;
an injection is then made through the fibers of the external oblique
into the inguinal canal, the canal then opened, and round ligaments
located and freed. As it is being drawn through the internal ring,
the tissues around this point down to the peritoneum are infiltrated
with a fine needle, bearing in mind the position of the deep epigastric
artery. By proceeding in this way the drawing of the ligament through
the internal ring and stripping back of the peritoneum causes no pain.
Suprapubic cystotomy is performed the same in the female as in
the male, but it is easier to perform cystotomy by the vaginal route,
as has already been described, and if to be left open for drainage
it is more convenient, as the patient can wear a urinal and not be con-
tinually soiled as with a suprapubic opening. *
In operating within the abdominal cavity only a limited number
of operations are feasible, and only then under favorable conditions,
with free movability of the parts. In the presence of adhesions or
inflammation about the tubes or ovaries the case should be operated
by other methods. The abdomen is opened in the middle line after
infiltration, first of the skin and subcutaneous tissues, then pass-
ing the needle down to the interval between the recti muscles; after
these have been opened the subperitoneal tissue, which is quite re-
laxed at this point, is now infiltrated, this infiltration anesthetizing
the peritoneum. (See chapter on Abdominal Operations.) After
a few minutes this is opened. Retractors should be gently used, as
any undue traction on the abdominal wall will cause pain. The uterus
should be raised into the wound with the hand, not with volsellum or
other toothed instruments, unless the point at which they are applied
has first been infiltrated. A variety of operations are now possible—
26 -
4O2 LOCAL ANESTHESIA
salpingo-oophorectomy, when these parts are free, by lightly infiltrating
the broad ligaments, pelvic and uterine attachments, of these parts
along the proposed line of incision on their anterior and posterior sur-
faces (Fig. II.4); pedunculated ovarian cysts, when not adherent, are
quite easily removed in the same way; subperitoneal fibroids removed,
or resection of the body of the uterus performed by first lightly infil-
trating the proposed line of incision; this can often be omitted, as the
uterus has very little sensation; ventrosuspension, or fixation, is quite
easily done, and usually without any discomfort; if any is experienced,
light infiltration can be resorted to on the fundus, where the Sutures
are to be placed.
line of anesthesia. de
Fig. II.4.—Shows uterus, broad ligament, and attachments. Series of circles shows
line of infiltration beneath anterior peritoneal fold of broad ligament. Where this line
crosses uterus, in shaded portion, infiltration is more liberal. On left is seen small line
joining longer one at about right angles, and shows area infiltrated when limited to one
side as in the case of removal of tube and ovary only. Similar infiltrations are made
posteriorly, as described in text.
Intra-abdominal operations for purposes of shortening the round
ligaments may be done under local anesthesia, but it would be prefer-
able to do an external Alexander, unless the cavity has already been
opened. The ligaments may be doubled on themselves and sutured,
using light infiltration at these points if necessary or fixed behind the
uterus. The various operations of drawing the ligaments through the
abdominal wall, at or near the internal ring, may also be done by first
raising the abdominal wall gently and infiltrating the peritoneum and
subperitoneal tissue around these points, as well as the tract through
which the forceps will be passed through the abdominal wall in grasp-
ing the ligaments, remembering the location in this neighborhood of

GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 403
the deep epigastric artery and vein and making the injection only
when advancing or withdrawing the needle.
Cesarean section can be performed under local methods when other
forms of anesthesia are contra-indicated.
The following is from a paper by Drs. R. K. Smith and Jacob
Schwarz, of San Francisco, read at the San Francisco Medical Society,
May, IQIo, and amply describes the procedure. In both cases there
was a contracted pelvis with contra-indications to general anesthesia;
in both cases mother and child survived:
“The Solution used was novocain (o.50 per cent.), to each Io c.c.
of which was added I drop of adrenalin solution (I: Iooo). This solu-
tion was freshly made and boiled for five minutes before using. Two
points, one 9 cm. above the umbilicus and the other a like distance
below it in the median line, were infiltrated with a drop of the solution,
and from these, as points of departure, the solution was injected
about a diamond-shaped area subcutaneously and then subfascially.
The line of the incision was not infiltrated in either of these cases.
The amount of solution used was about 75 c.c. in Case 1 and 60 c.c.
in Case 2, and it is my belief that a smaller amount might be sufficient.
“The operation was carried out as follows: Incision through
the abdominal wall, 15 cm. long, with its center opposite the umbilicus,
peritoneal cavity packed off with gauze, uterus incised with knife
down to the placenta for about I inch, and the incision rapidly enlarged
with Scissors to about 15 cm.; the placenta pushed aside, the membranes
ruptured, the child grasped by its feet and extracted, and the pla-
centa removed from the uterus while it was in situ; the uterus lifted
out of the abdominal cavity and surrounded by pads dipped in hot
saline solution. In Case I the hand was introduced through the
incision into the cavity of the uterus and one finger passed through
the cervix, this was followed by a Goodell dilator, which was carried
through the cervix and stretched open. This was not necessary in
Case 2, operated upon on April 4, 1910, as the cervix was completely
dilated before beginning the operation. The uterine incision was closed
with deep and superficial interrupted sutures of chromic catgut, and
these buried with a continuous Lembert suture of the peritoneum,
the peritoneal cavity wiped out, and the wound closed.” -
CHAPTER XX
- SPINAL ANALGESIA AND EPIDURAL INJECTIONS
SPINAL analgesia had its beginning in the experiments of Dr. J.
Leonard Corning, which were published in the “New York Medical
Journal,” October 31, 1885.
Corning first experimented on a dog, injecting a 2 per cent. cocain
solution in the lower dorsal region, and obtained paralysis of motion
and sensation in about five minutes, followed by complete recovery,
without noticeable ill effects. He next injected a man suffering from
sexual disturbances, using 30 min. of a 3 per cent. cocain solution,
between the eleventh and twelfth dorsal vertebrae. There was no
result in eight minutes, and the injection was repeated, producing
anesthesia and incoördination of the lower extremities. The anes-
thesia was complete, as proved by various tests; urethral sounds were
passed and other manipulations used about the genitalia. This was
done in the office. In an hour the patient was able to leave with
sensation still impaired, but otherwise no worse for his experience.
Corning, in concluding, states:
“Whether the method will ever find an application as a substitute
for etherization in genito-urinary or other branches of surgery further
experiences alone can show. Be the destiny of the observation what
it may, it has seemed to me, on the whole, worth recording.”
Corning was not a surgeon, and did not have the opportunities
of applying this method further, and, as it did not attract favorable
*
f : .
* To Prof. R. Matas is probably due the credit of having performed the first operation
under spinal analgesia in America. An operation for hemorrhoids was performed upon a
young colored male in the Charity Hospital Clinic on December 18, 1899, Profs. F. A.
Larue and H. B. Gessner assisting, with the author, then an intern in his service. The
spinal canal was reached between the fourth and fifth lumbar vertebrae, with escape of
spinal fluid; two injections were made five minutes apart, each about I c.c. of I per cent.
cocain in normal salt solution; anesthesia immediately followed, and was complete from
the waist-line down, with a gradually lessening degree of anesthesia reaching as far up as
the neck. Some reaction followed the operation (chill, nausea, vomiting, and temperature),
which shortly subsided, the patient making a good recovery.
An unsuccessful attempt had previously been made on November Ioth with beta-
eucain, but the resulting anesthesia was unsatisfactory. (Jour. Amer. Med. ASSOC.,
December 30, 1899, p. 1659.)
404
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4O5
attention at the time on the part of his American confrères, it was
accordingly dropped until revived some years later by Continental
Surgeons. -
In these experiments Corning had aimed to inject the fluid be-
tween the spinous processes, and permit it to be carried by the veins
to the cord. Corning deals with the subject again in 1888, and in
1894 appeared his book on “Pain in its Neuropathological, Diagnostic,
Medicolegal, and Neurotherapeutic Relations.”
Corning's intention was to make the injection into the neigh-
borhood of the cord; he did not aim to puncture the membranes;
whether this occurred or not, he must at least have gotten within the
canal, else it is hard to understand how anesthesia resulted, as it
could not take place from diffusion, as the cord is well isolated from
its perivertebral Surroundings, and it is not at all likely that it could
be carried to the cord by the surrounding circulation in any effective
quantity. This, then, was the first attempt at a paravertebral injec-
tion, but was, no doubt, intraspinal if not intrameningeal.
Real interest in the method was aroused in 1891 by the lumbar
puncture of Quincke, which was developed largely by the activity of
Continental surgeons, notably by Bier and Tuffier.
Bier, with admirable courage, first tried the method upon himself,
to more accurately observe its effects. The anesthesia was satis-
factory. It was followed by a slight headache.
The method was soon in general use on the Continent and in
America, but did not so early gain followers in England, probably due
to conservatism, as well as to the fact that here general anesthesia
had reached a high plane of development, being regarded as a specialty
and given largely by professional anesthetists.
The wave of enthusiasm which followed the general introduction
of the method has been followed by a reaction, and we find, upon the
study of the large number of statistics which are now available, that
the method cannot compare in safety at the present stage of its devel-
opment with general anesthesia. If it is to compete with general
anesthesia it must be by the introduction of some other agents or
methods than those now in use.
It has, however, a decided field of usefulness in selected cases and
under certain conditions. -
A thorough understanding of spinal anesthesia is not possible
without the consideration of certain anatomic, mechanical, and physio-
logic facts. -
406 LOCAL ANESTHESIA
ANATOMY
The spinal cord ends opposite the lower border of the first lumbar
vertebra (in the child, opposite the third lumbar), in the filum termi-
nalis, which is given off from the conus terminalis (Fig. 115).
The spinal cord and cauda equina are surrounded by the same
membranes as the brain-viz., dura, arachnoid, and pia.
, spinal ganglia
-
>~~ anterior
median fissure
-
w
spinal nerves
º ſlumbar)
spinal dura mater * W.
cauda.' '
equina
~ corrygºal nerve
Fig. 115–An anterior view of the lower portion of the spinal cord. The dura mater has
been divided longitudinally. (Sobotta and McMurrich.)
The dura, continuous with that which invests the brain, is a loose
sheath, not attached to the bony framework of the spinal canal, but
separated from it by loose areolar tissue containing a plexus of veins
which are most numerous in front and on the sides, less so posteriorly.
The dural sac terminates at the third sacral segment. It is attached




SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4O7
by fibrous slips to the posterior common ligament, and is largest
in the cervical and lumbar regions. At the beginning of the cauda
equina the nerves lie in bundles on each side, with an appreciable
interval between, through which runs the filum terminale. They
approach each other lower in the lumbar region and surround the filum,
which continues to the termination, of the dural sac and blends with
its attachment to the periosteum of the coccyx.
On the side of the cord and in the cauda equina the motor nerves
lie in front, the sensory behind, on the side of the cord, separated
by the ligamentum denticulatum in the cauda equina, still separated
by an irregular cribriform membrane. This accounts for the motor
nerves not being more regularly reached and affected by the anes-
thetic, fluid in spinal puncture.
The arachnoid is separated. from the dura by a slight interval,
the subdural space.
Within the arachnoid membrane, the subarachnoid space, is the
Cerebrospinal fluid. This space is of considerable size and is largest
at the lower part of the spinal canal. Within this space is the cauda
equina. This space communicates above, through the foramen of
Magendie, with the subarachnoid and general ventricular cavity of
the brain. The space is partially divided by a longitudinal cribriform
membrane, connecting the dura with the pia membrane.
It will be seen from the above description, as well as by consult-
ing Fig. II.5, that the most favorable site for the spinal puncture is
the midlumbar region, for here the cauda equina lies in two bundles
on each side of the middle line, and is less likely to be injured by a
needle introduced at this point, which has been termed the “cisterna
terminalis” by Donitz.
PHYSICAL AND PHYSIOLOGIC FACTORS INFLUENCING THE MOVE-
MENTS OF THE CEREBROSPINAL FLUID
It is generally believed that the cerebrospinal fluid moves freely
in and out of the spinal canal with changes in the position of the
body, that is, from the erect to the recumbent or inverted positions.
The tension within the membranes must certainly be influenced by
such changes, but I doubt that there is as free movement to and from
the cranial cavity as we have been led to believe, for the following
Tea,SOI1S .
The spinal canal is surrounded by an unyielding bony framework,
and is uninfluenced by pressure upon it from the outside. The
space within the canal must always be filled, a vacuum cannot exist.
408 LOCAL ANESTHESIA
If the body is inverted and the fluid runs into the cranial cavity, what
is to take its place? The position is certainly not favorable for an
engorgement of the venous plexuses around the canal; besides, the
inverted position readily congests the large venous cavities within
the skull and must increase the pressure here, making less room for
the entrance of the spinal fluid. That such change of position does
influence the pressure within the canal we must readily admit, but
that there is any extensive to-and-fro movement is no doubt an error,
but probably takes place to only a limited extent.
Investigations made upon the open canal of animals is of no value,
for here the atmospheric pressure which enters through the opening
permits the fluid to be displaced. The results of experiments upon
animals cannot be applied to man. The dog has only about 6 c.c. of
cerebrospinal fluid throughout the entire subarachnoid space, while
in the monkey it is still less, and the cord and meninges fill the canal
closely.
Further evidence upon this subject has been furnished by the
Very thorough investigations of A. E. Barker, from which I will later
quote rather freely. (See Isotonic Qualities and Specific Gravity of
Anesthetic Solutions and Movements of Cerebrospinal Fluid.)
ANESTHETIC AGENTS
Nearly all agents that have been used for local anesthesia have
at Some time or other been used for spinal analgesia. That none
of these have proved thoroughly satisfactory accounts for the change
from one to the other.
The advent of spinal anesthesia was before the introduction of
some of the more recently discovered anesthetics.
Cocain was the first used, and was soon found to be too dangerous
to justify its continuance by the majority of operators, but is still
used by some few; 6 to Io min. of a 2 to 4 per cent. Solution is the
strength usually employed.
Béta-eucain was employed, but was found unsatisfactory.
Stovain next claimed attention. It was introduced by Fourneau
in 1904, and was first used by Chaput and Tuffier, and for a time be-
came the agent most in use. It possessed some noteworthy proper-
ties. Its solutions were able to stand boiling without decomposition,
and it possessed mild antiseptic properties. It is freely soluble in
water and is of a feeble acid reaction. It has a more marked effect
upon motor nerves than has cocain, paralyzing all the sphincters—anal,
uterine and vesical—as well as producing general muscular relaxa-
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4O9
tion when it comes in contact with the motor roots. This is of decided
advantage in Operating upon the abdomen and perineum; in laparot-
Omy it permits wide retraction of the abdominal muscles, which greatly
facilitates the work. This paralyzing action on the motor nerves may
reach high enough to effect the respiratory nerves or even the centers
in the medulla, and thus add a grave danger to its action. It is some-
what irritating to the tissues as well as to the nerve-fibers.
Alypin has been used, but has been discarded as being unsuited
for use in the spinal canal.
Novocain, the least toxic (six times less than cocain) and least
irritating of all the local anesthetics, has been applied to spinal anes-
thesia, but has not proved generally satisfactory, and is, accordingly,
less used at the present time. Its action on motor nerves is much less
marked than that of Stovain, and there is, accordingly, less danger
of respiratory paralysis. The usual dose is about I gr.
Tropococain is the agent most popular at the present time, and is
being generally adopted by most operators. Less unfavorable results
have been reported from its use. From 4 to I gr. is the dose usually
employed. The smaller dose for peripheral operations, the larger
dose for abdominal operations and those upon the trunk.
The method of preparing the various agents differs largely in the
hands of different operators.
Most operators prefer to use 5 or Io per cent. strengths in sterile
Solutions of the various agents, using a sufficient number of minims
to give the desired strength of the drug. The solution used may
contain a definite quantity of sodium chlorid to make it isotonic with
the cerebrospinal fluid. This may be injected directly into the
spinal cord, or, as practiced by Bier, and Tuffier, at present, the re-
quired quantity of the solution is placed in the syringe and an equal
quantity of cerebrospinal fluid drawn into the syringe before injecting
into the canal. Similarly, the dry sterile salt may be placed in the
barrel of the syringe and dissolved in the aspirated fluid before injec-
tion. This last method is becoming more popular.
Tablets of the various drugs used in the usual strength employed,
with or without adrenalin, but usually containing a small amount
of sodium chlorid, are placed on the market by various manu-
facturers.
The tablets are sterilized and in sterile containers, and when mixed
with a definite quantity of sterile water produce a solution isotonic
with the cerebrospinal fluid.
The keeping qualities of the tablets for any length of time is some-
4IO LOCAL ANESTHESIA
what in question, particularly if they contain adrenalin preparations;
also the power of rendering and keeping them sterile.
Sterile ampules, similar to those used for serums, each containing
the recognized dose of the agent in use, are put up by the various manu-
facturers in this country and abroad. It is a convenient and safe
method, provided the contents of the ampule can be thoroughly
depended upon. When about to be used they are first immersed in a
strong antiseptic solution—bichlorid, carbolic acid, or alcohol—
before being opened by the operator, who opens them just before he
is ready to withdraw their contents.
ISOTONIC QUALITIES AND SPECIFIC GRAVITY OF ANESTHETIC
SOLUTIONS AND THEIR MOVEMENTS WITHIN THE CANAL
It is absolutely necessary that the injected fluid be as nearly iso-
tonic with the cerebrospinal fluid and as free from irritating quali-
ties as possible. This, as determined by the usual physical tests to
which the liquid is subjected, is not reliable, as proved by the investi-
gations of Dr. A. E. Barker. As the subject is so thoroughly handled
by him, I will give it in his own words:
“To secure isotonicity might appear an easy matter at first sight,
but from my observations is not so. A 5 per cent. Solution of stovain
in distilled water freezes at about o.58° C., almost the same point as
that of blood-serum. If this were the only test applied it ought to
be isotonic with the blood. But if a drop of blood be added to a little
4 or 5 per cent. Solution of Stovain under the microscope, in five
minutes the red Corpuscles Swell and become pale, in ten minutes
are almost invisible, and in twenty minutes are all gone. The same is
seen if a drop of blood is added to 5 c.c. of these solutions in a test-
tube; but here the changes are apparently slower, as at the end of an
hour a few swollen, pale cells can still be seen, but in an hour and a
half they are all invisible.
“In a really isotonic fluid, such as normal saline (o.91 per cent.
Sodium chlorid) or normal glucose solution (5 per cent. of glucose),
the cells are seen in twenty-four or forty-eight hours unchanged.
“The hemolytic action of stovain, which I have tested in every
way I could think of, appears hitherto to have escaped notice. It has
been Supposed too readily that if its 5 per cent. Solution has the same
freezing-point as the blood it would be isotonic with it, but, as we have
seen, the blood-cells are destroyed by it. Even the solution prepared
for Bier, in the belief that it was isotonic (stovain, 4 per cent.; sodium
Chlorid, o. II per cent.; epirenin borate, or per cent.), I find to be
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4II
markedly hemolytic, tested as above on the microscopic slide and
in a test-tube. But further than this I have found that if to an iso-
tonic Solution of Sodium chlorid or glucose, in which blood-cells are
seen to be unaltered at the end of twenty-four hours, 5 per cent. of
stovain be now added, the cells rapidly swell, grow pale, and disap-
pear, no trace of them being found in one and one-half hours. No
combination of Sodium chlorid or glucose with stovain which I have
made hitherto has prevented this hemolytic action of the drug.
“Furthermore, it may be added that I have added a 5 per cent.
Solution of stovain with a freezing-point of —o.58°C. to an equal part
of cerebrospinal fluid, and found in this compound destruction of all
blood-cells in about one hour. Nothing is seen then under the micro-
Scope but débris and oily globules. This is as much as to say that a
5 per cent. Solution of Stovain injected into the spinal cord would be
hemolytic too.
“Leaving the point of osmotic tension for the present, and admitting
that we have no evidence to show that the small amount of the drug
injected has produced any injurious effect as the result of its hemolytic
action, there are other physical qualities which an injected compound
may possess which also appear to have attracted little or no attention.
“There are three ways in which an analgesic fluid injected in the
second lumbar interspace can make its direct effects felt in the mid-
dorsal region, or even higher, as is sometimes the case in this procedure.
These are either:
“(1) By slow diffusion; (2) by shifting of the whole column of cere-
broSpinal fluid, in which it is suspended upward; or (3) by gravita-
tion, if the injected compound be distinctly heavier than the liquor
spinalis.
“(1) Diffusion alone of one fluid in another is a slow process, and,
as we shall see, is unlikely to be the mode of spread of the injected
fluid in this procedure.
“(2) Bier and his followers have aimed at shifting the injected
compound upward or downward, with the whole mass of the cerebro-
spinal fluid, by raising or depressing the pelvis. That the cerebro-
spinal fluid does recede somewhat toward the head on elevation of the
pelvis is undoubted, but it is hard to imagine its doing so to such an
extent as to carry with it a cloud of fluid lighter than itself from the
second lumbar to the fifth dorsal vertebrae. I venture to think that
with such a fluid as he has used, whose specific gravity is I.ooš8, Sus-
pended in the liquor spinalis, whose specific gravity is I.oo79, that
what he has achieved by elevation of the pelvis has rather been a more
4I2 g LOCAL ANESTHESIA
rapid diffusion of the injected drug, due to the consequent oscillation
of the Spinal fluid, aided perhaps by vascular pulsation.
“(3) There remains, then, the third possibility, namely, that an
injected compound heavier than the liquor spinalis may be affected
by gravity, and sink through the latter in a way quite different to the
behavior of a fluid of less specific gravity such as that just referred to.
It is easy to observe the behavior of one fluid injected slowly into
another through a needle if the fluid be colored with anilin blue.
Provided that each be of the same temperature and specific gravity,
the injected liquid forms at first a distinct blue cloud, which slowly
diffuses itself through the whole mass, into which it enters if the latter
be in a state of rest. On the other hand, if the injected fluid be of the
same temperature, but of much greater specific gravity, it sinks rapidly
from the point of the needle in a definite stream to the bottom of the
second fluid, and remains there as a distinct stratum, without diffusion
for a time, proportionate to its density and viscidity.
“The densities of the only three compounds used in our series
compared with that of the cerebrospinal fluid are as follows at 15° to
17° C.:
“Liquor spinalis (from three patients, mixed fresh) = I.oo7o
I. Chaput’s Compound:
Stovain, Io per cent.; NaCl, Io per cent., distilled water, 8o per cent. = I.o831
2. Writer’s Compound: g
Stovain, Io per cent.; glucose, 5 per cent.; distilled water, 85 per cent. = I.O3OO
3. Bier’s Compound:
Stovain, 4 per cent.; NaCl, o.II per cent.; eperenin borate, o.o.1 = I.ooS8
“All these are, as we have seen, more or less hemolytic, tested by
immersion in them of blood-cells, the first much the most so (three
minutes), the two last about the same in this respect (one to one and
one-half hours). The first, a very heavy fluid, in which the common
salt is present at the point of saturation at ordinary temperature, has
long been used by Chaput and Tuffier with good results, but apparently
for other reasons than its density. Their grounds for employing such
a high percentage of common salt, as stated by the former, were
that M. Billon (Paris), who prepared the compound for them, hoped
thereby to prevent the splitting up of the stovain by the alkalinity
of the spinal fluid. That it does not do so is evident to any one who
adds some of their compound to the cerebrospinal fluid drawn off.
It will then be seen that the latter becomes almost at once milky.
If a little of the fluid in this state be examined under the microscope
it will be seen that this turbidity is due to the presence of small glob-
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4I3
ules of an oily nature, which, in the course of time, run together into
larger and larger globules.
“A solution of 5 per cent. pure glucose in distilled water freezes at
about osó” C., and is really isotonic, producing no effect on the blood
or tissue cells in twenty-four hours. Five per cent, stovain in normal
solution gives a specific gravity of I.or 26. The hemolytic action of
stovain cannot be avoided.
** - - - - -
Alypin, 5 per cent.; distilled water, 95 per cent.; sp. gr., 1.oo36; freezing-point, o.53
Novocain, 5 per cent.; distilled water, 95 per cent.; sp. gr., 1.oooo; freezing-point, o.555
Tropococain, 5 per cent.; distilled water, 95 percent.; sp. gr., 1.oiáo; freezing-point, o,545
Stovain, 5 per cent.; distilled water, 95 percent.; sp. gr., 1.oob.4; freezing-point, o,585
Cerebrospinal fluid, sp. gr., 1.oo70; freezing-point, o.56
Blood-serum, - freezing-point, o.56
“Drawing conclusions from the above, these fluids should behave
differently.
“Tropacocain, with its high specific gravity, should sink. The
uniformly good results obtained by many with this agent may be due
Fig. 116.-A photograph of a tracing from Braune's well-known plate of a frozen
mesial section of the female cadaverlying level. Details omitted for the sake of clearness.
Over the spinal canal, and following its curves accurately, is a glass tube filled with saline
solution of the same specific gravity as that of the cerebrospinal fluid = 1.oo70. Through
the middle vertical arm over the second lumbar interspace the hollow needle has been
introduced into the curved tube, and I c.c. of Chaput's solution (specific gravity 1.0831)
colored with methyl-violet has been slowly injected. This has run down rapidly into the
dorsal curve, and at the end of two minutes is seen as a dark stratum opposite the fifth
and sixth dorsal vertebrae. The dark area in the cervical portion of the tube is a shadow
on the glass. (Barker, in “Brit. Med. Jour.”)
partly to its physical properties, perhaps more so than to any specific
action on nervous structures. Allowance should be made for the be-
havior of any fluid after injection and during operation on the patient.
“By glass tubes bent to conform to the spinal canal, filled with

4I4 LOCAL ANESTHESIA
salt solution (specific gravity 1.oo70), and having an opening to con-
form with the position of the second lumbar space, the action of differ-
ent solutions in vitro has been studied. Of course, it is conceded
that certain vital phenomena would modify the conditions some-
what, but, in the main, what occurs here furnishes us with fairly cor-
rect evidence on most of the scientific physical points connected with
these injections in the living patient (Figs. II6-122).
“Each of the compounds to be colored with the same quantity of
methyl-violet, and used at the ordinary temperature of the air and
fluid filling the tube. It has been gently passed into the latter, as
Fig. 117.-Same as Fig. 116, but with the pelvis raised 3 inches from the level. In this
case I c.c. of Bier's solution has been similarly injected colored. This, having a specific
gravity of only 1.oos8, has not altered its position, except that, being lighter than cerebro-
spinal fluid (1.oo70), it has risen in the vertical arm. In this position it remains for a long
time undiffused. (Barker, in “Brit. Med. Jour.”)
on the living patient, with the usual needle through the vertical
arm over the second lumbar interspace. From frozen sections of
the cadaver, lying on its back, it may be seen that the highest point
of the canal from the level is in the cervical region. Next to this
a point between the third and fourth lumbar—that is, the point
at which the puncture for spinal analgesia is made. From this last
point the dural canal slopes downward in both directions. The
caudal incline ends for the dura opposite the third sacral vertebra.
The cephalic incline slopes from the point of puncture downward as
far as the fifth or sixth dorsal vertebra, when it begins to run up again
to reach its highest point at the third cervical vertebra. With the

SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4I5
head thrown downward on a pillow, as the writer believes it should
always be during intradural injections with heavy fluids, the foramen
magnum would be the highest point in the spinal canal. These curves
vary considerably in individuals and at different ages, but the above
may be taken as generally correct. Now, if it were possible to punc-
Fig. 118.-Three tubes, as in Figs. 116 and 117, but without the tracing behind. Into
the top one Bier's light solution has been injected, into the middle tube glucose stovain
(author's solution, specific gravity 1.03oo), and into the lower tube Chaput's. The pelvis
has been raised 3 inches as before. In the top tube Bier's compound, being lighter than the
fluid in the canal, has remained stationary; the glucose-stovain (1.0300) is still running
down. Chaput's, the heaviest compound, has already reached the dorsal curve and is at
rest. Photographed two minutes after infection. (Barker, in “Brit. Med. Jour.”)
ture the lumbar sac from behind, at the classical point, with the
patient lying on the back perfectly horizontal, a liquid heavier than
the spinal fluid would always flow for the greater part from the injec-
tion needle toward the dorsal curve and settle in a layer about the
fifth dorsal spine, while some of it would gravitate toward the caudal
end. This is actually what happens when the experiment is made

416 LOCAL ANESTHESIA
with the glass tube bent accurately to the curves of the spinal canal.
But in the living body there are practical difficulties in penetrating
from behind with the patient supine. However, if the injection be
made while the patient lies on the side (or face), as I have occasionally
done, and he then turns over on the back with the head thrown for-
ward, a heavy fluid should take the same course. That it does so is
almost proved by the regularity with which the analgesia produced
Fig. 119.-Sitting position for puncture when analgesia of the perineum is required.
The line from iliac crest to crest crosses the fourth lumbar spinous process, above which
the needle is entered. The patient is then gently laid on his back with the head and neck
well raised, all unnecessary movement being avoided. From a photograph by Dr. E.
Worrall. (Barker, in “Brit. Med. Jour.”)
by the Chaput heavy saline stovain-sodium-chlorid compound or the
writer's stovain-glucose one, though not quite so heavy (see above),
rises to about the episternal notch or a little higher—that is, the ,
region supplied by the sixth and seventh dorsal nerves. This varies a
little, according as the head and neck are raised, and so the dorsal
curve increases. This was so frequently observed in the second
50 cases, where the glucose-stovain compound was alone used, as to

SPINAL ANALGESIA AND EPIDURAL INJECTIONS 417
be remarkable. Of course this may be modified somewhat by raising
the pelvis a little, as has usually been done, to hasten the flow of the
º-
- -
Fig. 120-Glass tubes accurately bent to curves of spine, and filled with solution
of sodium chlorid of the same specific gravity (1.oo70) as that of the cerebrospinal fluid.
A, Sitting position. Tube curved to the line of the dural sac from occiput to caudal ter-
mination (frozen section, Braun). This has been injected with I c.c. of our heavy anal-
gesic compound (specific gravity 1.oz.30) of the same temperature as the solution in the
tube. The injection was previously colored with 1 per cent. methyl-violet. In the photo-
graph taken two to three minutes later it is seen to have run down to the sacral sac and to
remain unmixed there. In the living subject subsequently laid on the back it would again
flow a very little with the cerebrospinal fluid toward the head. B, The same, quite hori-
zontal. Shows the injection pooled in the dorsal curve two minutes after introduction in
the second lumbar space. A little has run down into the sacral sac. Of course, the patient
can never be injected actually on the back for practical reasons. C, Tube bent to a tracing
of the lateral curve with head and pelvis raised before injection, as in Fig. 121. The injec-
tion is seen collected in a pool about the sixth and seventh dorsal vertebrae two minutes
after introduction through the second lumbar interspace. This curve is greater than usual,
but represents what increase may be produced in it by inclining the back a little toward
the operator when the patient lies on the side, as in Fig. 121. From a photograph by Dr. E.
Worrall. (Barker, in “Brit. Med. Jour.”)
injected fluid toward the dorsal curve before it becomes diluted by
diffusion. It must not be forgotten, however, that in raising the

27
418 LOCAL ANESTHESIA
pelvis, while the head and neck are supported forward on a pillow,
the lumbar curve is diminished, while that of the dorsum is increased.
The pelvis would have to be raised very high indeed to bring the
level of the dorsal curve at the fifth or sixth spine above that of the
foramen magnum, with the head and neck bent forward, as described.
There is, therefore, but little likelihood of the heavy compound reach-
ing the medulla, or even into the cervical region at all. In some cases
in Germany inversion has been carried to a very extreme degree, the
head being unsupported, with the idea of displacing the whole mass of
the cerebrospinal fluid toward the cranial cavity. But we must remem-
Fig. 121.-Photograph of patientln typical position on side, with head and neck raised
and a 1-inch padded board under the trochanter and iliac crest. The line of the iliac
crests is given crossing the fourth lumbar spine. The level of the first cervical spine is
seen to be well above that at which the injection compound “pools,” and will be relatively
higher when patient rolls on the back, as in Fig. 122. From a photograph by Dr. E. Wor-
rall. (Barker, in “Brit. Med. Jour.”)
ber that in these cases the compounds have usually been of low spe-
cific gravity, and in the case of Bier's (see above) actually lighter
than the spinal fluid, so that it would not be likely to move as far as
the neck by any oscillation of the column of the spinal fluid. There
have been a few cases, however, both in France and Germany, in
which the analgesia has extended over the whole head, as well as the
rest of the body, without injury, but the details as to injection and
pelvic elevation are not given. They were probably instances of
diffusion helped by oscillation. Personally, I have never aimed at
getting a higher analgesia than to the transverse nipple line. At the
caudal curve the effects of a heavy compound can be limited in the

SPINAL ANALGESIA AND EPIDURAL INJECTIONS 4I9
same way by position. If the patient be seated on the edge of the
operating-table, with his feet on a low chair and his back rounded,
the heavy fluid injected at the second lumbar interspace at once
tends to run into the sacral dura, as we see also in our tube experi-
ments. Here it accumulates at the end of the dural sac, where it
quickly affects the roots of the nerves supplying the parts about the
anus and the perineum. This is seen so constantly, even where anal-
gesia is less satisfactory in other parts, that it suggests that when
the injection is made in the sitting position most of it makes its way
caudally, and it requires much and immediate elevation of the pelvis
and oscillation of the cerebrospinal fluid to dislodge it from the sacral
- -
- - - -
- . º º
- - - ---
Fig. 122.-Photograph of the same patient gently rolled over on the back with the same
relations of head, neck, and pelvis. The line across the fourth lumbar spine is seen, and also
that the dorsal curve is deeper than the previous lateral curve. From a photograph by
Dr. E. Worrall. (Barker, in “Brit. Med. Jour.”)
sac. That is why I have thought it well in some cases to puncture
with the patient lying face downward, with a hard pillow crosswise
under the umbilicus, so as to decrease the lumbar curve. In this
position a heavy fluid runs toward the head, and if after half a min-
ute the patient roll over on the back and have a pillow placed under
the head and neck pretty high, the injected fluid collects in the lower
dorsal curve. This prone position, otherwise desirable, has the
defect that the flow of cerebrospinal fluid is not so good unless the
patient is told to raise his head and to bear down, but I think this
can be overcome. But so great is the tendency for the injection
fluid to be in part locked up in the sacral sac when the injection is

42O LOCAL ANESTHESIA
done in the sitting position, that if I want the analgesia to reach to
the border of the ribs for an abdominal operation, the patient is placed
on the side with the knees drawn up as high as possible for puncture,
and thus all the compound flows at once upward and all of it col-
lects in the dorsal curve as the patient rolls over on the back. In
such cases, where the patient remains for any time on the side after
the puncture, we have noticed that the analgesia reaches higher up
at the end of the operation on the side on which he has been lying.
This seems to indicate clearly that the bulk of the compound has run
along the roots on that side, but that it ultimately becomes segmental,
affecting both sides, though still unequally.”
Dr. Babcock, of Philadelphia, who has had extensive experience
with Spinal analgesia and has carried out some original investigations
in this field, reverses the procedure of Barker and uses solutions of
lighter Specific gravity than the cerebrospinal fluid, using alcohol as
the means of accomplishing this purpose. Stovain is the agent usu-
ally employed, and is put up in Sterile ampules containing Io per cent.
alcohol.
The high lumbar puncture is usually employed, and the patient
then placed in the inverted or Trendelenburg position, with the idea
that the injected fluid being lighter will float upward in this position
toward the caudal end of the dural sac.
The position undoubtedly has its advantages in any operation
under spinal puncture. Should syncope occur it is best combated
in this position, and should it be necessary to resort to artificial
means of respiration the position is also favorable. However, certain
objections may be found to the supposed movements of the injected
fluid within the canal. The anesthetic fluid, if undisturbed by physi-
cal influences, should float upward and remain in that position, but
the attraction of alcohol for water is so great that its influence must
Soon be exhausted, when the injected solution may then gravitate
downward, thus producing first an ascent and then a descent of the
injected fluid.
The action of glucose solutions, as suggested by Barker, is quite
different, as the glucose is but slowly affected by the surrounding
cerebrospinal fluid, and its anesthetic content quite thoroughly
exhausted before the specific gravity is appreciably altered.
The influence of alcohol upon the injected fluid can be tested
in the following way: Take two sections of glass tubing connected
by a short joint of rubber tubing, stop one end and fill with a clear
Solution of known specific gravity, color a little solution of lighter
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 42 I
specific gravity with methylene-blue, and add 10 per cent. alcohol;
by injecting some of this second solution with a hypodermic syringe
into the first, passing the needle through the rubber connection, its
movements within the tube can be observed (Fig. 123); it will be
seen to slightly ascend, when, after a few moments, some of it begins
to gravitate downward, finally distributing itself over a wide area.
Fig. 123–Author's simple device for testing movements of solutions of different
specific gravity when injected one within the other, the injected solution being colored.
Consists of two sections of glass tubing connected by a short section of rubber tubing.
Letting alone experimental tests of this kind, which cannot accurately
represent conditions within the body, the proof must come from
clinical experience. This has been satisfactory in Dr. Babcock's
hands, although the method does not seem to have been extensively
adopted.

422 LOCAL ANESTHESIA
INDICATIONS AND CONTRA-INDICATIONS
In its present stage of development all operative procedures,
except in very exceptional cases, should be restricted to the perineum,
external genitals, and lower extremities. While the lower abdominal
walls are easily reached by the analgesic influence, the most likely
operation here is for hernia, and, as this is so easily and safely done
under local anesthesia, Spinal puncture for that purpose should
never be performed. While it has often been used for abdominal
operations, particularly those of the lower abdomen, unless the anal-
gesia is very high, complete analgesia is not Secured, as the parietal
peritoneum receives many nerve-fibers from the lower dorsal nerves,
and the analgesia would have to be carried beyond the recognized
safe limits to reach these nerves. Certain observers have claimed that
the intestines become contracted under anesthesia with stovain and
tropacocain; it, therefore, may have some claim in operations for
ileus. Gray also states that the intestines become anemic. Its power
also of relaxing the abdominal walls may be of aid here.
In all operations, from Poupart's ligament down, in which general
anesthesia is contra-indicated, and which cannot be performed under
local, regional, or vein anesthesia, then spinal analgesia should be
considered. Such cases will be found in patients suffering from ad-
vanced pulmonary, Cardiac, or renal disease. Particularly, in tuber-
culosis and cardiac disease should great care be exercised not to let
the analgesic fluid reach the higher centers.
Spinal puncture has been demonstrated to be irritating to the
kidneys, but less So than general anesthesia, consequently should
have the preference here.
In diabetes Braun has observed coma to follow spinal puncture.
It is also indicated in pronounced alcoholics, and may be indi-
cated in cases suffering from pelvic neuroses—visceral, uterine, and
rectal; here it may act beneficially, in a way similar to the epidural
injections of Cathelin.
It is contra-indicated in nervous and hysteric patients, in children
and in extreme old age, in all suppurative processes (here it may
create a “locus minoris resistentia” for suppurative processes in the
cord by the organisms already in the blood); in recent syphilis,
locomotor ataxia, and other diseases of the spinal cord or central
nervous system, advanced arteriosclerosis, high temperature, and
all acute infectious diseases. If after puncture the spinal fluid is found
to be turbid, no injection should be made.
General anesthesia acts on the highest centers first and progresses
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 423
downward; spinal anesthesia acts on the lowest centers first and
progresses upward. In dealing with a certain class of cases, notably,
extensive crushing injuries of the lower extremities with shock, spinal
anesthesia would seem, on theoretic grounds, to be highly indicated,
provided its action can be limited to the lower centers, as further
depression of the heart and vasomotor centers would precipitate death.
The value of nerve-blocking in such cases has been clearly demon-
strated, but a sufficient number of observations on the action of spinal
puncture in such cases, from which conclusions can be drawn, is not
yet available.
J. Blumfeld, in writing on the subject, states the following: “The
effects of spinal anesthesia in minimizing shock, by cutting off per-
ipheral impulses, will probably prove its great claim to utility in the
future. There is no reason why this valuable effect should not be
employed in conjunction with general anesthesia. The extremely
Small amount of general anesthesia that need be administered to a
patient who has been subjected to stovain reduces any risk of the
general anesthesia to a minimum; only enough need be given to insure
absence of all consciousness.”
Jonathan M. Wainwright, of Scranton, Pa., in his Address on
Surgery before the Medical Society of the State of Pennsylvania
(“Pennyslvania Med. Jour.,” November, 1905), makes a careful study
of spinal analgesia and other anesthetics, especially in their relation
to shock. He concludes, from experimental evidence, that in con-
ditions where (I) shock exists ether very markedly increases the
shock; (2) if the spinal canal be injected with cocain or Stovain,
traumatism, amputations, etc., which would otherwise cause marked
shock, do not have any effect; (3) the amounts of cocain or stovain
needed for spinal analgesia do not have any systemic effect when
absorbed into the general circulation; (4) the fall of the temperature,
noted in some cases after spinal injection, is a mechanical effect,
and is not due to the drug. The following general conclusions are
also offered: Ether and chloroform are much more dangerous than
has formerly been supposed. In many cases of shock, ether or chloro-
form will cause death, even without an operation. They should not
be given where local or regional anesthetics are at all practicable.
TECHNIC
About one hour before the administration of spinal puncture it is
advisable to give a hypodermic of a small dose of morphin (; or § gr.).
Many observers prefer the combination of morphin and Scopolamin,
424 LOCAL ANESTHESIA
as recommended by the writer, before major operations under local
anesthesia. By this method the bad after-effects are much lessened
and the analgesic effect much intensified and prolonged. The dose
should never be large enough to produce Somnolence, but just suffi-
cient to allay the fears and anxiety of the patient by inducing drowsi-
ness and indifference. Morphin, gr. § or 4, with Scopolamin, gr. Hºw,
is the dose recommended by the writer. Under this influence the
fear and psychic influences which may contribute to shock are greatly
lessened or entirely eliminated. This is particularly useful in nervous
patients and in all patients for amphitheater work. Coming before
Nru-º
72 in A. for
76er/ºncºre.
Fig. 124.—The point for lumbar puncture. (“Keen’s Surgery.”)
large crowds, and being operated in the conscious state, is bound to
have some disturbing effect even upon the most stoical.
Dr. Fowler has recommended I's gr. of strychnin a quarter of an
hour before the puncture, stating that it lessens shock, respiratory,
and circulatory disturbances. While this method is theoretically
good, it does not seem to have found much favor, and it would seem
better to use the morphin and Scopolamin as above suggested. Their
action in allaying nervousness and excitement in the patient, and
thus arresting psychic influences, operate more toward lessening
shock than stimulation of the centers with strychnin.

SPINAL ANALGESIA AND EPIDURAL INJECTIONS 425
This technic should vary according to whether you are using an
anesthetic liquid heavier than the cerebrospinal fluid or not. The
heavier liquids, as used by Barker, have much to recommend them, for
you can more easily determine and control its movements within the
Subarachnoid space. The point of puncture should also vary according
as to whether the operation is to be above or below Poupart's ligament.
As the Spinal cord ends at the Second lumbar vertebra, no injection
should be made above this point. The method of Jonnesco, which
we regard as dangerous, will be discussed in a subsequent section.
Jonnesco's method is not necessary, however, to obtain high anal-
gesia. By using Solutions of high specific gravity, and changing the
position of the patient, we can control the movements of the solution
within the canal and secure high analgesia if desired.
There are three points for puncture, as ordinarily practiced–
the intervals between the second and third, third and fourth, and
fourth and fifth lumbar vertebrae (Fig. 124).
The interval between the third and fourth vertebrae is commonly
known as Quincke's point; between the fourth and fifth, as Tuffier’s.
Also to determine whether the injection is to be made with the
patient: -
(1) Lying on the side and remaining subsequently in the hori-
zontal position;
(2) Sitting during puncture, with subsequent horizontal position;
Or,
(3) In either of the above, with subsequent inverted (Trendelen-
burg) position.
The larger the quantity of anesthetic solution used, the higher the
anesthesia.
The value of the use of solutions of high specific gravity, and
controlling their action within the canal, is amply stated by Dr.
Barker.
The positions in which the patient is placed after having received
the injection have the most important influence upon the extension
upward of the anesthesia. A comparison of these may be made, tak-
ing only three varieties for the sake of brevity:
(1) Injection, with the patient lying down on the side and remain-
ing horizontal;
(2) Injection in the sitting posture, the patient subsequently lying
on the back;
(3) Injection in the sitting posture, followed by elevation of the
pelvis.
426 LOCAL ANESTHESIA
With the first of these we find the lowest, with the second a higher,
and with the third the highest extension upward of anesthesia.
The cause of the difference is very simple.
If the horizontal position is changed into the sitting, the liquid
cerebralis runs out of the cranial cavity into the spinal cord. If the
patient again lies down, the fluid runs back once more into the skull.
When the Trendelenburg position is produced a still larger amount
of the cerebrospinal fluid flows toward the head. Seeing that the
analgesic compound injected is carried with the spinal fluid, the ex-
tension of the analgesia upward or downward is determined by the
movement.
“This all means simply that the heavy fluid containing the drug
flows from the highest point of the lumbar curve (point of puncture)
to the lowest, in the lateral or dorsal depression, by virtue of the
specific gravity (1.0230), the liquor spinalis (specific gravity I.Oo?o)
being in a state of rest.
“But if any other proof were needed of the behavior of our heavy
analgesic fluid in the canal, it is furnished by those cases in which
we have kept the patient on the side from before the injection to the
end of the operation, without any change of position at all. One or 2
cases out of many will suffice: It was necessary to amputate a young
man’s left leg below the knee. He was laid on the left side, with the
head well raised on pillows, the left shoulder resting on the table. In
this position, which was not altered in the least until he left the table,
the injection was done in the second lumbar interspace. In the course
of five or six minutes paralysis of sensation was absolute in the de-
pendent left leg. In the right leg sensation was never lost at all.
The patient was quite comfortable throughout the amputation.
“In another case of operation for varicose veins of the left thigh
and leg the same was done with like results. Dr. Henry Head, who
was present and was kind enough to test the phenomena of sensation
and motion most minutely, stated that the right (upper) thigh and
leg remained entirely unaffected, both as to sensation and motion.
This can only be explained by the flow of our heavy analgesic com-
pound along the roots of the lumbar nerves of the left side without
any diffusion. It certainly was not augmented by diffusion, as the
functions of the other limb remained unaffected throughout. It would
be incorrect, then, to call this medullary anesthesia, as is sometimes
done” (Barker).
In operations upon the perineum Barker uses the sitting position;
in all others, the injection is made in the recumbent position.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 427
Only in high abdominal operations is it necessary to slightly ele-
vate the pelvis, so that the fluid will more readily gravitate toward the
dorsal curve.
Several operators, notably Bier, Braun, and Donitz, have spoken
of the use of a band, which is placed around the neck sufficiently tight
to produce venous congestion of the head. This raises the intra-
cranial tension and forces the cerebrospinal fluid downward. After
its removal the fluid flows back again. They have at times resorted
to this procedure, but it would seem superfluous, and not at all neces-
sary, as an adjunct to our technic.
If the injection is to be made in the sitting position the patient
sits on the side of the table, a stool being provided for his feet. The
elbows are placed upon the knees, with the head and shoulders bent
Fig. 125-Spinal puncture needle (1) compared with ordinary needle (2). Note short,
sharply beveled point on spinal needle; this is the same type of needle as is used for reaching
the branches of the fifth nerve at base of skull.
far forward—the scorcher position—so as to arch backward the lum-
bar regions and increase the interval between the lumbar spines.
The kind of needle used in making the puncture is of much im-
portance. It should have a sharp but short point; if the point is made
too long only a part of it may enter the membranes, permitting the
escape of the cerebrospinal fluid, causing you to think you are well
within the sac, but may slip out, or, when the injection is made, only
a part of it may enter the subarachnoid space, the remainder escap-
ing extradurally and lead to a failure in anesthesia (Figs. 125 and I31).
A long sharp point may also produce damage to the cauda. It is
preferable, therefore, that the needle have a short, sharply-beveled
point, and be from 3% to 4 inches long, and of as small a caliber as
possible consistent with strength, and permitting a lumen of suffi-
cient size so as not to be readily choked.

428 LOCAL ANESTHESIA
Some use a cannula for making the injection, which is passed down
the lumen of the needle after the puncture is made, thus insuring the
entrance to the Subarachnoid space; this, however, does not seem
necessary and increases the size of the needle (Figs. 126, 127).
With skill and care, in a normal subject, no great difficulty is
experienced in entering the sac. Any good all-glass syringe will
answer for making the injection. A metal syringe should never
be used, as you should always be able to see the condition and watch
the movements of the fluid within the syringe.
A syringe of 2 c.c. capacity is ordinarily sufficient; but if you
decide to use the cerebrospinal fluid as the solvent medium for the
\\ , * ,
\\, -
ºff.
*.*
t
*...*
* *º º - º s Fig. 127.—Demonstrating the use of
Fig. 126.-Syringe and cannulas for the inner cannula for injection into the
Subarachnoid anesthesia. (According to subarachnoid space. (According to Bar-
Barker.) (“Keen's Surgery.”) ker.) (“Keen's Surgery.”)
dry sterile powder previously deposited in the barrel of the syringe,
then a large one, up to 5 c.c., is to be preferred; or, if it is preferred to
mix the anesthetic fluid within the syringe with an equal quantity of
cerebrospinal fluid before final injection, as practiced by Bier and
Tuffier, the larger syringe should be selected.
The syringe, needles, etc., used for spinal puncture should never
be used for any other purpose, and should be sterilized by boiling
in plain water. No alkalis or antiseptics should be used. Alkalis
destroy the anesthetic agents, and a small dose of antiseptic may
prove irritating to the cord.
The site of puncture should be prepared by cleansing with Soap
and water only, or, if antiseptics are used, they should be carefully



SPINAL ANALGESIA AND EPIDURAL INJECTIONS 429
-
washed away before making the puncture. Tincture of iodin may be
as satisfactorily used here as elsewhere for sterilizing purposes.
Before beginning everything should be tested to make sure that
it is in perfect working order. Sterile water should be injected through
the needle to determine if the lumen is freely open, as well as to clear
out any possible small particles of metal loosened from its lumen
during the process of sterilization.
In making the puncture the needle may be used alone or fitted
to an extra syringe, which will serve as a handle. The objective site
Fig. 129.-Showing flexed posture of
patient and point for making lumbar punc-
Fig. 128.-Side view of lumbar punc- ture, 1 cm. to the side of the median line,
ture between the third and fourth lumbar and between the third and fourth lumbar
vertebrae. (“Keen's Surgery.”) spines. (“Keen's Surgery.”)
for the injection is the midline of the subarachnoid space, between
the two divisions of the cauda equina. If the needle enters on either
side, its point may enter the bundle of nerves and the discharged solu-
tion be more or less retained among them, leading to one-sided or
unsatisfactory anesthesia. Some operators make the puncture directly
in the middle line, between the spines of the vertebra. In this position
it is more difficult to avoid the bony prominences with which the
needle may come in contact.

43o LOCAL ANESTHESIA
An easier and equally reliable method is to enter slightly from the
side (Figs. 128-136).
The point of puncture having been decided upon, we will say the
interval between the third and fourth lumbar vertebrae (the spine
of the fourth vertebra lies on a level with a line drawn between the
highest points of the iliac crests), the finger of the left hand is placed
on the spine of the fourth vertebra, and the needle entered about
1
# inch to the right and just below the highest point of the spine,
-
Fig. 130.-Section through vertebral column. Needle in position between spines of fourth
and fifth lumbar vertebrae.
directing the needle slightly upward and inward at such an angle
that after penetrating 2% or 3 inches it will reach the dura in the
midline. The distance from the surface to the dura varies within
certain limits, according to the stoutness or size of the individual,
but it is usually about 2% or 3 inches. Before making the punc-
ture, it is, of course, desirable to render the skin anesthetic, either
with ethyl chlorid or with a syringeful of weak novocain or Schleich
solution.
After the skin is passed very little sensation is felt by the patient.

SPINAL ANALGESIA AND EPIDURAL INJECTIONS 43I
Just before entering the canal the needle is felt to encounter the dense
fibrous ligaments of the spine. When this is pierced, no further resis-
tance is felt and we feel we are in the spinal canal. The only proof
of entering the Subarachnoid space is the escape of cerebrospinal fluid.
If this does not escape we cannot feel that we are properly within the
membranes. If this does not occur we may advance the needle a little
further, but we should be careful not to advance too far, or we may
completely pass through the Subarachnoid space into the parts on the
anterior Surface of the canal. The failure to secure a proper entrance
within the membranes may be due to their flaccid condition and their
being pushed forward in front of the needle. If such is the case, and
the patient is asked to hold his breath and bear down, the membranes
become tense and the needle will enter more readily.
If now the fluid does not escape, and we feel sure we are within
the membranes, the failure of the flow may be due to the needle hav-
ing become plugged during its passage through the tissues. Gentle
aspiration can be made by fitting the empty syringe to the needle.
If nothing comes, the needle had better be withdrawn and re-inserted,
either in the same interspace or in another. Should only blood appear
and no cerebrospinal fluid, the needle had better be withdrawn and
re-inserted, care being taken to first free its lumen of any clots. Occa-
sionally the flow of fluid is preceded by a drop of blood, which is of no
moment.
The plexus of veins surrounding the membranes are more numer-
ous in front and on the sides, less so behind; the escape of blood with
the anesthetic fluid into the sac is one of the causes of failure in anes-
thesia as well as a possible cause of after-trouble.
After the subarachnoid space has been reached, it is generally
advisable to allow a quantity of cerebrospinal fluid to escape equal
to the volume of anesthetic fluid to be injected. Some allow the
escape of much more, as much as 5 to Io c.c., or even I5 c.c., claiming
to have less unpleasant after-effects when this is resorted to, but it is
thought best not to allow too much to escape.
Dr. S. P. Delaup, of New Orleans, states, “It has been a common
observation that patients with a high spinal pressure, as evidenced by
a strong, continuous flow of the cerebrospinal fluid, are more power-
fully influenced by the analgesic solution than those in whom the
spinal fluid escapes by drops. It is possible that the diffusion oc-
curred too rapidly in such cases.”
The syringe containing the anesthetic solution is now fitted to
the needle and very slowly injected. The injection should never be
432 LOCAL ANESTHESIA
made rapidly, but always slowly, for we must remember that the
cerebrospinal fluid is really a water Cushion on which rest the brain
and cord, and any shock transmitted to it will traverse throughout its
entire extent. The point of puncture is sealed with sterile adhesive
plaster or cotton and collodion.
After the puncture and injection have been successfully made
anesthesia Sometimes fails to set in. In this event we may have resort
to one of two procedures—either we may repeat the injection, pro-
vided the two injections will not exceed the safe maximum dose
of the agent employed, or we may resort to general anesthesia if the
case is suitable. .
It is usually advisable to allow the patient a light meal before
making the puncture, the same as before any other major procedure
with local anesthesia. They stand the puncture and subsequent opera-
tion better, and are less liable to be disturbed by nausea and fainting
while on the table. The objection to this is that, in the event of failure
to secure the needed anesthesia, it may prevent the administration
of a general anesthetic. During the progress of the operation, after
Successful puncture, it is a good practice to allow the patient some
stimulating drink—toddy, coffee, or milk-punch.
Adrenalin.—Whether or not adrenalin should be used in the spinal
Canal is a question much in doubt. At one time it was most favor-
ably thought of by most of the leading operators—Bier, Tuffier,
Braun, and Donitz—but later there has been a reaction againstits use.
Braun has explained its favorable action by stating that it contracts
the vessels in and around the cord, thus creating a larger space in the
dural sac and producing a flow of cerebrospinal fluid in this direction,
thus lessening the tendency of the anesthetic solution to ascend and
produce disturbing symptoms. These views, however, have radically
changed. That adrenalin does prolong and intensify the action of
some anesthetics when injected into the spinal canal with others,
notably tropacocain, it is contra-indicated, as the anesthetic agent
opposes the action of adrenalin. We cannot draw a conclusion here
by a comparison of the action of adrenalin when used in the tissues
with a local anesthetic, where it is of decided value.
In the spinal canal we are dealing with an open lymph-sac. The
adrenalin here must expend its influence upon the vessels of the
cauda, and cannot aid directly in retaining the anesthetic in situ.
The congestion and ecchymosis sometimes seen to follow its action
in the tissues may here, in the loosely supported vessels of the cord
and meninges, have a more pronounced effect, which may lead to
unpleasant sequelae.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 433
FAILURES
They average about 9 per cent., but differ greatly with different
Operators.
This includes cases of complete failure, partial, incomplete, or
unilateral anesthesia, and short or delayed anesthesias.
Failures may occur even when every detail of the technic is care-
fully carried out and the injection is apparently successful. Many of
these cases have been attributed to idiosyncrasy on the part of the
patient, but this is hardly likely to be the case, except in a very limited
number of cases, for if such frequent idiosyncrasies existed we would
have more failures from local anesthesia. It is more than likely due
to Some technical error made possible by anatomic abnormalities, an
Fig. 131.-Schematic representation of proper and improper kind of needle puncturing
membranes of cord show how use of improper needle may withdraw cerebrospinal fluid
by point partially entering membranes, but permits escape of most of injected fluid outside
of membrane.
imperfect puncture of the membranes, the lumen of the needle only
partially entering them, permitting an escape of cerebrospinal fluid,
but when the injection is made most of the Solution escapes extra-
durally (Fig. 131), or may have become entangled in the bundles of
the cauda equina, producing only partial or unilateral anesthesia, due
to the puncture being made too laterally.
The agent used may have become inert through oversterilization
Or age. -
The delayed appearance of anesthesia cannot be satisfactorily
accounted for. In some few cases the delay has been as long as half
an hour. Hollander reports a case in which, after three-quarters of
an hour's delay, anesthesia set in.

28
434 LOCAL ANESTHESIA
Schleich and other observers have shown that the admixture of the
various anesthetic agents with blood renders them inert. This has
been attributed to the strong alkalinity of the blood, but, as the
cerebrospinal fluid is also alkaline, it must be due to other factors, too.
But it may be that the wounding of a vein, permitting an escape of
blood into the Subarachnoid space, may account for some of the
failures.
IN OBSTETRICS AND GYNECOLOGY
Various results have been recorded from the use of spinal analgesia
in obstetric work, some reporting fairly satisfactory results, while
others report indifferent results with numerous failures. It has been
stated by those whose experience qualifies them to speak, that when
once labor has well started the spinal puncture does not interfere
with the uterine contractions, but may, if it ascends high enough in
the canal, lessen the power of the abdominal muscles, and thus remove
a valuable aid to the expulsive power of the uterus. When used it
should be the aim to limit its action to the pelvic canal and perineum,
consequently low puncture, between the fourth and fifth lumbar,
should be used, with elevated shoulders following. The great objec-
tion is that the analgesia is not of sufficient duration and often passes
off before the completion of labor, but when successful aids greatly
in the relaxation of the pelvic outlet, permitting the painless application
of forceps and later repair of the perineum when necessary. It is, how-
ever, not a method for routine use in obstetrics, but may be advisable
in exceptional cases. Abdominal cesarean sections have been suc-
cessfully performed under its action, but here it is simply abdominal
surgery, and meets with the same success and is governed by the same
conditions influencing other abdominal work with this method.
The same may also be said of abdominal gynecologic operations.
Regarding vaginal operations, we have shown that the perineum and
external genitals are particularly favorable for spinal analgesia;
their nerves come from the lowermost portion of the dural sac. Operat-
ing with solutions of high specific gravity, with the head and shoulders
elevated, there should be little danger from toxic effects upon the
higher centers. These regions are the first to feel the anesthetic effect
and the last to return to normal sensation.
If spinal analgesia were the method of choice this would be a
favorite field for work; but we must accept the weight of the evi-
dence of statistics, and admit that the mortality is greater even
under the most favorable conditions. If general anesthesia is posi-
tively contra-indicated, a large number of vaginal operations can be
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 435
safely and easily performed under local anesthesia, leaving a much
reduced number, which, if necessary, may then be performed under
Spinal analgesia.
MILITARY SURGERY
Here it may find a field of usefulness, but as yet no opportunities
have arisen where it could be put to practical tests. Military surgeons
have taken different views on the subject. The great danger would
be that the absolutely necessary details of asepsis may be neglected.
This is most likely to be the case on the field.
Dr. Thomson, in the “Journal of the Association of Military Sur-
geons,” writes as follows:
“Tropacocain spinal analgesia has its place in military surgery,
especially field work in time of war, because it offers the following
advantages: (1) It obviates the necessity for the storage and trans-
portation of the bulk of general anesthetics. (2) Is much more eco-
nomical than general anesthesia. (3) The immense saving of time
and attention in its administration. (4) The saving in operative
personnel, dispensing with the necessity of anesthetizers. (5) The
saving in the number of attendants for individual patients—after
operation under spinal anesthesia the patient does not require such
attention as under general anesthesia. (6) The saving of a number of
bearers—under spinal anesthesia, patients are much more able to
assist themselves. (7) Its employment on the field of battle, at dress-
ing stations, ambulance stations, etc., must be the means of relieving
much suffering, as well as the prevention of shock from pain, and, at
the same time, render the wounded man better able to assist himself
to reach the field hospital.”
PHENOMENA OF ANALGESIA: COURSE AND DURATION
In the great majority of cases the onset of analgesia is without
any noticeable disturbing effect upon the patient, and generally begins
to make itself felt in from three to five minutes, Sometimes longer,
being ushered in by a sense of numbness or tingling in the lower
extremities. Analgesia appears first in the external genitals, perineum,
and inner side of thighs, then progresses down the limbs and up
toward Poupart's ligament or higher, depending upon the point of
puncture, position of patient, volume and strength of the agent
used. It extends always to a higher level posteriorly than anteriorly
on the trunk, owing to the general direction of the spinal nerves.
The return of sensation is in inverse order to its development,
436 LOCAL ANESTHESIA
disappearing first in the parts last affected and last in the perineum
and external genitals.
The duration is from about three-quarters of an hour to an hour
and a half; tropacocain slightly shorter than cocain or stovain.
As anesthesia develops the reflexes begin to disappear. Some
muscular incoördination is usually seen, and usually more or less
paresis of the lower extremities—sometimes complete paralysis. The
motor disturbances are always more marked with stovain, hence
its danger in high analgesias, where it may paralyze respiration.
Tactility is usually not affected, except by large doses, which
paralyze all sensation.
The symptoms vary much with the size of the dose as well as in
different individuals. By using only the smallest efficient dose many
of the unpleasant symptoms will be avoided.
Occasionally analgesia is ushered in by muscular twitchings of the
lower extremities, more or less violent; slight weakness, nausea or
vomiting may occur, or Sweating may be noticed. As a rule, there is
not much difference in the pulse in low anesthesia. In a few cases
the above symptoms are most marked associated with symptoms of
collapse. The respiration may at first be rapid, labored, or sighing,
becoming more shallow later; the pulse becomes rapid and feeble.
The patient may be seized with a feeling of terror or be so collapsed
as to be indifferent. Respiration may cease entirely and death be
imminent. -
The muscular relaxation of the anesthetized parts will depend upon
whether the anesthetic fluid has reached the anterior roots of the
spinal cord and varies with the different solutions used—always more
marked with stovain.
DANGEROUS EFFECTS
As a rule, the bad effects increase in number and severity the
higher the analgesia and the larger the dose used. Our aim should
be to find an anesthetic agent, combination, or technic which will
leave the heart’s action, vascular pressure, and respiration unin-
fluenced.
Zur Verth, writing from Bier's clinic, has the following to say:
“Until this ideal is realized it is wiser to keep the blood-pressure
at its normal figure, with drugs to act on the heart, when high spinal
anesthesia is attempted. Bier has been having the blood-pressure
studied during the last six years, and Zur Verth gives his experience
with 44 patients anesthetized by the spinal technic with or without
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 437
epinephrin. A drop in blood-pressure of more than 25 per cent. was
observed in 18 cases, but the operation had been high in the rectum
or on the kidney or bladder in all of these, and thus above the level
of the absolutely ‘safe' region. The addition of the suprarenal prepara-
tion did not seem to have any influence in preventing the drop in
blood-pressure, while it reduced the extent of the analgesia, but seemed
...to prolong it. A few whiffs of ether augment the force of the heart
without acting on the vessels. Epinephrin, on the other hand, acts
on the tonus of the vessels; this raises the blood-pressure if the heart
is working as usual, but the epinephrin acts also on the heart, reducing
its energy. As the blood-vessels are contracted at the same time,
the result is naturally more in the line of a collapse of the whole
cardiovascular system than in the line of stimulation. That the col-
lapse does not occur, as a rule, is due to the special counteracting in-
fluence of Some component of these suprarenal preparations acting
directly on the heart function.”
There are definite limitations placed upon our means of combating
dangerous symptoms. An excessive dose, whether absolute or rela-
tive, as in the case of idiosyncrasy, is more immediately and hope-
lessly fatal than is the case after ether or chloroform, because it
cannot be antagonized by mechanical eliminative means. In the
treatment of emergencies one runs the danger of fatal syncope if we
sit the patient up; if we invert him, we increase the toxic action on the
higher centers and he may succumb.
McCardie gives the following statistics, gathered from the large
clinics: -
“In 23,955 cases of spinal analgesia, collected from forty observers,
there were 29 deaths, or one in every 826. Strauss collected, 30,000
cases, with I death to 18oo cases. At another time he said that
tropacocain had a record of 7059 cases, with 5 deaths, or I in 14II.
Hochmeier and König, when speaking of the present position of Spinal
anesthesia, collected from many hospitals and clinics 2400 cases, with
12 deaths, or I in 200. Hochmeier concludes that spinal analgesia
should only be used when ether-rausch and local anesthesia will not
suffice, and there is marked contra-indication to general anesthesia.”
AFTER-EFFECTS
About one-third of the cases have slight headache and nausea,
coming on within an hour or two after the injection and passing off
within a few hours. Slight elevation of temperature (about Ioo” F.)
is usual, but subsides in a few hours.
43
438 LOCAL ANESTHESIA
In a small percentage of cases, 2 or 3 per cent., the headache is
quite severe, and in some may become quite unbearable and last for
five or six days or longer. Occasoinally the temperature rises quite
high, sometimes reaching Ioa F., and may require a day or two to
subside. The pulse may become rapid and weak and profuse Sweat-
ing occur. Collapse may come on immediately or is sometimes de-
layed for from a few hours to several days after the puncture. More
marked symptoms of meningeal irritation (meningismus) may appear,
with headache, stiffening of the muscles of the back and neck, which
may persist for several days, associated often with disturbances of
motion and sensation in the lower extremities. These cases may
clear up in a few days or go on to the development of purulent menin-
gitis.
Vertigo, more or less persistent, is occasionally observed. The
writer had a case in which the vertigo lasted for six weeks. The
patient was almost unable to walk during this time.
The character of after-symptoms may vary greatly, and are by no
means regular as to kind or time of onset.
Reynier reported a case of syncopal collapse in a patient the eve-
ning after an operation under spinal anesthesia. She revived under
prompt artificial respiration. In another case unbearable pains in the
leg, commencing a week after the operation, persisted for a week. In
another case a fracture of the malleolus had been reduced under spinal
anesthesia without mishap. A month later the man was affected with
complete paralysis of the arms, legs, and back of the neck. He could
not hold his head erect or turn it; the head dropped back whenever
it was passively lifted. He was like a jumping-jack whose strings have
all been cut. As there were no sensory disturbances, hysteria was out
of the question. The paralysis gradually subsided, and he left the
hospital in apparently normal condition at the end of two weeks.
Reynier has also heard complaints from patients that they could
not walk so well as before their operation under spinal anesthesia.
Guinard was one of the first and most enthusiastic adherents of spinal
anesthesia, but he stated that he had completely abandoned it since
his experience in 3 cases. In the first a woman of fifty passed suc-
cessfully through a vaginal hysterectomy. Three months later she
developed paresis of the legs, with incontinence of urine and feces, and
died with symptoms of softening of the brain within the year; this
result also occurred in a second case. In a third case the patient died
suddenly three weeks after a simple suture of a perineal laceration
under spinal anesthesia.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 439
Incontinence of urine and paralysis of the anal sphincter have
frequently been observed, more frequently the former. They usually
require no special treatment other than providing for the discomfort,
as they usually clear up in a few days.
That Some of the late after-effects may be due to causes other
than the puncture and injection is, of course, possible, but the reports
of these cases are too numerous to leave any doubt that the great
majority are the direct results of the spinal analgesia.
Gangrene has frequently been reported as occurring in various
parts of the lower extremities and buttocks.
The after-effects are of two kinds: the immediate, due to the
toxic action of the injected drug on the nerve-centers, and the late,
the irritating results of the injection. That the immediate effects are
not due to the systemic action of the drug, but to its extension up-
ward and direct action on the higher centers, is amply illustrated by
the following experiments of Dr. Ryall:
“Two possibilities at once strike us when we come to consider the
causation of respiratory paralysis: (1) Are they the results of re-
absorption of the drug into the general circulation? or (2) are they
caused by the ascension of the analgesia solution in the dural sac
and the direct contact with the vital centers in the cerebral nervous
system? We know that the rapidity of the reabsorption of drugs
dissolved in the cerebrospinal fluid of dogs, on account of the activity
of the reabsorption surfaces, is generally much more rapid than that
of the subcutaneous cellular tissues. The same amount of poison has
a much more toxic action in subdural than it has in Subcutaneous
injections.
“That the extension of the drug in the dural sac is the essential
cause, and that the reabsorption into the circulation is quite, or for
the greater part, irrelevant, is proved by the following experiments:
“(1) When novocain, in the same dose (o.o.3 gm. per kilogram
body-weight) and same concentration is injected into rabbits, we find
(a) in intradural injections there is always at once intense and per-
sistent fall of the blood-pressure and frequently death within a few
minutes; (b) in intravenous injections there is an immediate fall of
the blood-pressure, but it is of very short duration, and death only
supervenes if the injection has been made with great rapidity; (c) in
intramuscular injections there is no action on the blood-pressure
which can be recognized. From this comparison one must draw the
conclusion that in subdural injections the reabsorption of the poison
cannot possibly be the only cause, and never the chief cause, of the
44O LOCAL ANESTHESIA
poisoning. For no matter how rapidly it may be sucked up out of the
dural sac and reabsorbed from the subcutaneous cellular tissue and
muscular system, the intensity of the action must still remain far
behind, as compared with the immediate flushing of the circulation
with the poison, such as takes place in intravenous injections, and
yet we see much more severe and prolonged poisoning which, moreover,
runs an entirely different course in intradural injections. This fact
can only be explained thus: that the course of the poisoning in intra-
dural injections is characteristically not caused through the rapidity
of the reabsorption, but through the direct action of the poison on the
substance of the central nervous system. It is only after contact with
the central organs that the course of the poisoning becomes impressed
with the characteristic stamp.
“(2) In a second series of experiments the dural sac was closed
before the injection was given by means of a ligature encircling the
membranes and cord at the height of the upper thoracic portion of
the spine. When o.o.3 gm. of novocain per kilogram body-weight was
injected subdurally below the ligature (which under normal circum-
stances would, without exception, cause a violent fall of the blood-
pressure, and which frequently resulted in the death of the animal) the
blood-pressure did not alter at all. Injections of the same dose above
the ligature generally killed the animal at once.” Similar experiments
were undertaken and like conclusions drawn by Heneicke and Laiven.
- We know, through the experiments of Aducco and Mosso, that a
drop of concentrated solution of cocain deposited on the floor of the
fourth ventricle will cause the immediate death of the animal.
Guinard’s observations upon patients who had been operated upon
under spinal puncture showed that in those suffering from bad after-
effects there was a marked rise in the pressure of the cerebrospinal
fluid, as demonstrated by a second puncture, and the symptoms were
relieved by allowing the escape of Io to 20 c.c. of fluid.
Patients who showed no after-symptoms were found to have no
change in the pressure of the cerebrospinal fluid.
Ravaut and Aubourg found in disturbed cases a great number of
leukocytes in the spinal fluid, but no bacteria. In cases that were not
disturbed the appearance of the fluid and its tension were not changed.
This aseptic puriform condition of the cerebrospinal fluid is met
with in other conditions. It has been reported occurring with otitis
media, syphilis, and many suppurative conditions. When encoun-
tered in the course of spinal puncture, it should be a contra-indication
to further procedure and the injection should not be made.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 44T
The possibility of hemorrhage within the dural sac, the result
of the puncture wounding some small vessel, must also be considered
as a cause for the after-effects in some cases. When it is remem-
bered how often the puncturing needle withdraws blood, it is not
unlikely that complications from this cause occur oftener than is
Suspected.
EXPERIMENTAL WORK
The introduction of spinal analgesia has stimulated experimental
work within the spinal canal, and investigators have tested the effects
of various Substances introduced into the canal. The introduction of
Sterile water has been found to produce disturbances of motion, but
affecting Sensation very little. Sicard has injected dogs weighing
about 20 or 30 pounds with 200 c.c. of 5 per cent. salt solution and
produced marked disturbances in motility, but it disturbed sensa-
tion only slightly.
Oelsner and Kroner report the experiences at Sonnenburg's clinic
and the results of considerable experimental research. They experi-
mented with injections of salt solution cooled to freezing-point,
after withdrawal of a corresponding amount of cerebrospinal fluid.
The ice-cold fluid does not injure the tissues, while the anesthetic
effect justifies, they say, further trials of this method; especially, they
add in conclusion, as none of the methods of spinal anesthesia in vogue
to date are entirely free from possible evil effects, and never can be
free from them, as they are based on the introduction of a foreign
chemical substance which must inevitably do more or less injury.
Klapp's experiments on dogs showed that the addition of oil to
the Solution of cocain entirely abolished all symptoms of intoxication.
When the cocain was in an oily vehicle, total anesthesia could be
induced in the dog without the slightest symptoms of intoxication.
The capillaries and lymphatics are probably unable to take up the
emulsion as rapidly as in an aqueous solution, and hence the cocain
remains longer at the point of injection and is very slowly absorbed.
Glycerin also retards absorption.
We know that in the use of oily solutions of anesthetics locally
the anesthetic effect is greatly prolonged, owing to the inability of
the lymphatics to take up the oil, and the danger of toxemia thus
greatly lessened, but the method has other disadvantages and has
never found favor.
When used in the spinal canal, if the solution was permitted to come
in contact with the higher centers, the danger would be just as great
as with watery Solutions, or probably more so, as it would take longer
442 LOCAL ANESTHESIA
for the oily solution to be removed by absorption, and oily solutions,
being ordinarily lighter than the cerebrospinal fluid, would be ex-
pected to float upward.
The danger in spinal analgesia, as has been shown, is not that of
general toxemia through absorption, for the dose is always within
safe limits, but for its local action on the vital nerve-centers.
The addition of small quantities of gum arabic to the analgesic
solution has been experimented with by some, who claim for it that
it does not interfere with its anesthetic action, but minimizes the
dangers by preventing absorption by the higher centers; this, however,
is unlikely. It no doubt owes any advantage it possesses to its greater
specific gravity, thus keeping the solution away from the higher
CenterS.
But if anything of its kind is to be used, it is far better to use
glucose, which is normally a constituent of certain parts of the body,
as advocated by Barker, and referred to at length elsewhere.
Of considerable interest was the discovery by Meltzer of the
anesthetic effects of magnesium salts when injected into the spinal
canal. Meltzer first experimented on monkeys, and found it to be a
motor and sensory paralysant. In one animal he injected what would
have been a lethal dose. In twenty-five minutes respiration had
ceased. Tracheotomy was done and artificial respiration was insti-
tuted. The heart, which had nearly stopped through asphyxia, now
regained its force and rate. Artificial respiration was continued for
seven hours, but, as there was no effort on the part of the animal to
resume its own respiration, it was continued for seven hours longer,
the heart during this time acting perfectly. At the end of this time
spontaneous respiration was resumed. The animal recovered com-
pletely and was apparently in good condition.
This experiment seemed to prove conclusively that death is due
to paralysis of respiration alone, the heart apparently not being
affected.
Meltzer found that o.o.6 gm. per kilogram was not dangerous in
monkeys. He suggested one-third this amount to be used on man,
giving I c.c. of a 25 per cent. Solution of magnesium sulphate to each
25 pounds body-weight. Following these suggestions, operations were
performed under its use, and it was used for a time extensively in teta-
nus, both by spinal injection and by hypodermoclysis; but, while it
controlled the convulsions often for twenty-four hours at a time, the
high temperature characteristic of this disease continued and the
patients succumbed from exhaustion, without there being any gain
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 443
in the reduction of the mortality. The method was, accordingly, dis-
continued as offering no advantage.
Canestro experimented with it on dogs, using adrenalin in addition,
and confirmed Meltzer's observations. He stated that it was free from
irritating effects on the tissues, and could find no histologic changes
in the nervous system or kidneys.
COMPLICATIONS AND SEQUELAE
The simple tapping of the spinal canal for purposes of examination
has at times been followed by after-effects similar in kind, though
usually less severe, than those we are accustomed to see following
spinal analgesia. The experiments of Guinard and Kozlowski, and later
confirmed by Stolz and Schwarz, show that the intraspinal injection
of sterile water, or even normal salt solution, is followed by after-
disturbances. Any change in the tonicity of the cerebrospinal fluid
will cause a change in the cerebrospinal pressure, lowering or raising
it accordingly as hypo- or hypertonic Solutions are used.
Clinically, we are well familiar with the symptoms of increased
cranial pressure the result of other causes.
Certainly the most serious complication is paralysis of respiration.
When this occurs, artificial respiration should be instituted at once,
either by using the arms, as in the Sylvester method, or, if the ap-
paratus is at hand, the use of the Matas-Smyth pump, with a Meltzer
intratracheal tube attached, or attached to a simple bellows, as
used for anesthesia. Either of these methods, if vigorously persisted
in, even in bad cases, runs a fair chance of success, as the heart usually
continues to beat for quite a while after respiration ceases. Tra-
cheotomy, with the passage of a tube down the trachea, may, of course,
be resorted to, but is no more effective than the other methods and
consumes valuable time.
URINARY CHANGES
Numerous observations made on the urine show that spinal anal-
gesia is irritating to the kidneys. Albumin and casts have frequently
been noted, but of short duration. The changes may appear in a few
hours or be delayed several days, disappearing a few days later. No
permanent changes or no fatal results from renal effects have been
recorded.
All the agents used may show this effect; stovain slightly more so.
As compared with the renal changes following anesthesia, Tomas-
chewski gives 60 per cent. for spinal analgesia compared to 72 per cent.
444 LOCAL ANESTHESIA
for general anesthesia. He also states that 66 per cent. of major opera-
tions under local anesthesia show slight traces of albumin.
Csermak, in a study of 60 cases with stovain, gives 39 in which
the urine remained normal. Albumin appeared in I2; albumin and a
few white blood-cells in 6; albumin and granular casts in 2; albumin,
granular casts, and white blood-cells in I.
Hartleib, in making similar observations, found stovain to produce
albumin in 78 per cent. of cases; in 20 cases with tropacocain only I
showed albumin. These observations have been amply confirmed by
others.
EFFECTS ON THE NERVOUS SYSTEM
Many observations and experiments have been made to show the
effect of spinal analgesia upon the spinal cord and nerves within the
canal. Nearly all of these investigations were with stovain. We
know that Stovain affects both motor and sensory nerves, also that it is
irritating. Necrosis has at times been noted following its use locally.
Prolonged paralysis, at times ending in death, has been recorded fol-
lowing its use. It was consequently to be expected that nerve changes
should occur. They are, however, in the great majority of cases,
transient. These findings emphasize the great danger of using spinal
analgesia in patients suffering from diseases of the nervous system.
Spielmeyer has examined the central nervous system in 13 cases
dying after spinal analgesia. In I case death was the result of the
puncture, the patient dying forty hours after, the other 12 cases
dying of other causes following operation. In all cases stovain was
used.
The changes, for the most part, consisted in degeneration of the
motor ganglion cells of the anterior horn, and were seen low down and
high up in the cord. In some the changes were so pronounced that
they would seem to be irreparable, but that none of these changes
were discovered in cases where the dose did not exceed o.9 gr. In
the case dying as a result of the puncture, 1.7 gr. had been used.
Here paralysis of respiration had been the first sign of trouble. His
experiments on dogs gave the same results; when small doses were
used, no change could be detected.
Klost and Vogt's experiments agree with Spielmeyer. They found
chromolysis in some of the anterior motor cells. Direct injections of
the anesthetics into the substance of the cord further confirmed their
toxic action. When normal salt solution was used instead of the
anesthetic solution no changes were observed, showing that they were
not of mechanical origin.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 445
Wossidlo and Lier’s investigations were equally as interesting,
and agree in the main with the experiments of others. Wossidlo con-
cludes that tropacocain was less dangerous than stovain or novocain,
but that their effects were not serious enough to prevent the use of
the drugs in this method.
Particularly interesting and thorough were the investigations of
Spiller and Leopold, which I quote as follows:
“The technic of our experiments consisted in performing lumbar
puncture on five dogs, with careful avoidance of infection. The
stovain solution used on dogs D and E was boiled. The dose of each
stovain injection varied from o.o.5 to 2 gm., and, except in dogs A and
B, in each of which only one injection was given, the injections were
usually at intervals of two or three days.
“The symptoms may be divided into the temporary and the per-
manent. The temporary consisted of flaccid paralysis and complete
or partial sensory loss. The hind limb showed flaccid paralysis, while
the entire body frequently showed the loss of sensation, implicating
even the ear. Bladder and rectal control was lost, and the tendon
reflexes where either diminished or absent. These symptoms oc-
curred immediately or several minutes after the injection was given,
and persisted from one to several hours. -
“The permanent symptoms consisted of ataxia, decreased sensa-
tion, and, in dog E, loss of patellar reflex. The symptoms became per-
manent after the third injection, remaining until the end of the
experiment. The ataxia was recognized by the irregular gait, and the
tendency to stand with the hind legs well apart and the peripheral
part of the hind limbs well on the ground.
“Axis-cylinders in the periphery of the anterolateral and posterior
columns were found here and there considerably swollen; some were
of large size; swollen axis-cylinders were seen in the root entrance of
the posterior columns, but otherwise not in the posterior columns ex-
cept near the periphery. A moderate degree of cellular reaction to
the stovain was detected in the pia and roots of the cord in the form
of round-cell infiltration, but never as cells of polynuclear type. This
is not a surprising finding, and resembles what is seen in tabes. One
would expect some cellular reaction to a poison affecting the nervous
system as does stovain. A very slight perivascular round-cell infiltra-
tion was seen here and there in the cord; it was so slight as to be of no
importance, and its existence was disputable. “The swelling of the
axis-cylinders in the anterior and posterior roots was very distinct,
and the swelling affected most of these axis-cylinders. One forms the
446 LOCAL ANESTHESIA
impression that the axis-cylinders were more swollen in the anterior
than in the posterior roots.
“The posterior columns in the lumbar region were degenerated, as
shown by the Marchi method, throughout a transverse section, but
much less so in the ventral zones. The reflex collaterals were also
much degenerated, and the degenerated fibers could be traced forward
into the anterior horns. Small black dots were found along Some of
the anterior roots within the spinal cord, and this finding indicates
a moderate amount of degeneration here. A slight degeneration was
found by the Marchi method along the periphery in the anterolateral
columns; it was far less intense than in the posterior Columns. In
the thoracic region the degeneration of the posterior Columns was Con-
fined to the columns of Goll; the columns of Burdach seemed to be
intact. The degeneration of the anterolateral columns in the thoracic
region was insignificant. The lumbar sections were taken fully I# to
2 inches above the point of injection.
“Anterior and posterior roots, taken between the dural cavity and
the posterior ganglia, were teased in the fresh state and stained with
a 1 per cent. aqueous solution of osmic acid. They presented Con-
siderable degeneration, chiefly in the form of minute black granules
within the neurilemma sheaths, and the degeneration was more ad-
vanced in the anterior roots. One could not conclude from this find-
ing that stovain affects the anterior roots more than the posterior;
rather, the finding would seem to imply that the roots, having been
affected by the stovain within the dural sac, secondary degeneration
would be found in the portion of the anterior roots examined, and
retrograde degeneration in the portion of the posterior roots examined.
Nerve-roots taken from within the interior of the dural canal, unfor-
tunately, were not examined by this method.
“The nerve-fibers in one of the lower spinal ganglia, placed in the
fresh state in I per cent. Osmic acid Solution, showed intense degen-
eration of the fine granular variety. The cells of the ganglion pre-
sented little degeneration.
“A nerve taken from the hind leg appeared intensely degenerated
when placed in the fresh state in osmic acid.
“It seems clearly demonstrated that stovain affects especially the
anterior and posterior roots; the degeneration of posterior root-fibers
in our sections was intense. What is worthy of note, the degenera-
tion of the intramedullary portion of the lumbar and sacral posterior
root-fibers in the thoracic region was still intense. The posterior
thoracic roots were unaffected. Stovain evidently also causes slight
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 447
degeneration in the periphery of the anterolateral columns, but has
less effect here than on the nerve-roots.
“These lesions obtained by us could not have been produced by
the trauma of the needle, as the sections of the lumbar region ex-
amined were 1% to 2 inches above the point of injection, and yet
the posterior and anterior roots were greatly degenerated.
“It would be unwarranted to apply these findings too strictly to
man, as no grave changes have been found as yet in the human spinal
cord. At most, our findings would show that repeated injections of
stovain might be injurious, and would make one cautious in employ-
ing several injections within a short time in the same subject. We do
not know whether stovain has more effect on the nervous system of
the dog than on that of man.”
The investigation shows further that the paralysis produced by
stovain is of the motor type, as the anterior roots were greatly de-
generated.
OCULAR PALSIES
Associated with the nervous lesions following analgesia are those
of the ocular muscles. These lesions are usually transient, appearing
five to ten days after puncture and disappearing in four to six weeks.
Occasionally the lesions are more persistent and, in rare instances,
have been permanent. They occur much more frequently in high
analgesia. Their frequency has been stated to be I to 400 or 500 cases.
Our colleague, Dr. Delaup, who employs almost exclusively the low
puncture, has had 1500 cases and his associates about 500 more. They
have not met with a single case of ocular paralysis. In the writers’
experience, and that of their associates, no cases have been observed.
The pathogenesis of these palsies is not at all clear. They have
occurred most frequently following the use of stovain, but also hap-
pen with the other agents. The irritating qualities of stovain and
its action on motor nerves is well recognized, but many of the other
agents are supposed to be free from such action. One theory is
that it is due to changes in the pressure of the cerebroSpinal fluid,
permitting pressure or traction on the nerves as they course along
the undersurface of the brain. This, however, is very unlikely, as it
would occur just as frequently with low puncture, and also with opera-
tions upon the spinal cord, when frequently large quantities of cere-
brospinal fluid escape. The fact that occasionally palsies have fol-
lowed cerebral operations has no analogous bearing here, for in such
cases the disturbance was most likely due to edema or congestion
following the procedure.
#.
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§ | * 3 #3 & #5 5 §
3. ſº {- ſº
Loeser. . . . . . . . . . . . Med. Klin., 1906, No. Io. . . . . . . . . . . . . . . . . . 45 || M. Novocain. . . . . . ? | L. Sup. oblique. . . . . . . . 5 6 mos. . . . . Recovery.
Loeser. . . . . . . . . . . . Med. Klin., 1906, No. Io. . . . . . . . . . . . . . . . . . 25 | F. Stovain. . . . . . . ? L. ext, rect. . . . . . . . . . . . 8 8 mos. . . . . Recovery.
Schoeler. . . . . . . . . . . Soc. d’Opht. de Berlin, 1906. . . . . . . . . . . . . . . P | ? | Stovain. . . . . . . ? | R. ext, rect. . . . . . . . . . . 8 P. . . . . . . . . P
Feilchenfeld. . . . . . . . . Centralb. f. prakt. Augenh., 1906. . . . . . . . . . . ? | ? | Stovain. . . . . . . P L. ext, rect. . . . . . . . . . . . I 2 * . . . . . . . . . P
Feilchenfeld. . . . . . . . Centralb. f. prakt. Augenh., 1906. . . . . . . . . . . ? | ? | Stovain. . . . . . . ? | L: ext, rect. . . . . . . . . . . . P ? . . . . . . . . . P
C. Adam . . . . . . . . . . München. Med. Wohnschr., 1906. . . . . . . . . . 33 || M. Stovain ? | L. ext, rect. . . . . . . . . . . . 2O 3 mOS. . . . . Still palsied at time of report.
Mühsam. . . . . . . . . . . Deutsch Med. Wohnschr., 1906. . . . . . . . . . . . 26 || M. Stovain. . . . . . . 15 || R. ext, rect. . . . . . . . . . . IO 31 days. . . . . Recovery.
Mühsam. . . . . . . . . . . Deutsch Med. Wohnschr., 1906. . . . . . . . . . . . 27 | F. Novocain. . . . . . 8 || R. ext, rect. . . . . . . . . . . 4. 22 days. . . . . Recovery.
Lang. . . . . . . . . . . . . . Deutsch Med. Wohnschr., Igoó . . . . . . . . . . . . 61 | M. Novocain. . . . . . I5 | Both ext, rect. . . . . . . . . #. II ſ . . . . . . . . . Persisted at time of report.
. 3O
Lang. . . . . . . . . . . . . . Deutsch Med: Wohnschr., 1906. . . . . . . . . . . . 41 || M. Novocain... . P L. ext, rect. . . . . . . . . . . . II 5 days. . . . . . Recovery.
Vossius. . . . . . . . . . . . Med. Gesellsch. Giesen, 1906. . . . . . . . . . . . . . . 60 | F. P. . . . . . . . . . . . . ? | L. ext, rect. . . . . . . . . . . . 6 P. . . . . . . . . Persisted after six months.
Blanluet and Caron. Soc., d'Qpht. de Paris, 1906. . . . . . . . . . . . . . . . 51 | M. Stovain. . . . . 5 | L: ext, rect. . . . . . . . . . . . Q ? . . . . . . . . . Persisted after six months.
CITIlêS. . . . . . . . . . . . Med. Klin., 1906. . . . . . . . . . . . . . . . . . . . . . . . . P | ? | ? . . . . . . . . . . . . . P One ext, rect... . . . . . . . . P * . . . . . . . . . | ?
Deetz. . . . . . . . . . . . . München. Med. Wohnschr., 1906, No. 28. . . . . P | ? | Stovain. . . . . . . ? | One ext, rect... . . . . . . . . I 2 ? . . . . . . . . . | ?
Rausscher. . . . . . . . . München. Med. Wohnschr., 1906. . . . . . . . . . . ? | ? | Stovain . . . . ? | One ext, rect... . . . . . . . . 8 ?. . . . . . . . . Recovery.
Rausscher. . . . . . . . . München. Med. Wohnschr., 1906. . . . . . . . . . . ? | ? | Stovain. . . . . . . P | One ext, rect... . . . . . . . . I3 ? . . . . . . . . . Recovery.
Loeser. . . . . . . . . . . . . ed. Klin., 1906, No. Io. . . . . . . . . . . . . . . . . . 25 | F. | Stovain. . . . . . . ? L. ext, rect. . . . . . . . . . . . I 2 I2 days. . . . . Recovery.
Schmidt-Rimpler. . . . Klin. Monatsbl. f. Augenh., July, 1907 . . . . . . P ? | ?. . . . . . . . . . . . . P | One ext, rect... . . . . . . . . P * . . . . . . . . . Recovery.
Schmidt-Rimpler... . . Klin. Monatsbl. f. Augenh., July, 1907. . . . . . P | ? | ?. . . . . . . . . . . . . ? | One ext, rect... . . . . . . . . P ? . . . . . . . . . Palsy persisted.
Adam. . . . . . . . . . . . . Deutsch. Med. Wohnschr., 1906. . . . . . . . . . . . 26 || M. | Stovain. . . . . . . P | One ext, rect... . . . . . . . . P * . . . . . . . . . Recovery.
Adam . . . . . . . . . . . . . Deutsch. Med. Wohnschr., 1906. . . . . . . . . . . . 26 | F. Novocain P One ext. rect... . . . . . . . . P P. . . . . . . . . . Recovery.
Scheppens . . . Clin. Opht., Nov. 25, 1908. . . . . . . . . . . . . . . . . P P | Cocain. . . . . . . . P ext, rect. . . . . . . . . . . . P ? . . . . . . . . . | P
aisch. . . . . . . . . . . . . München. Med. Wohnsohr., 1906. . . . . * * * * * * P ? | Alypin. . . . . . . ? | Both ext, rect... . . . . . . . P 5 days Recovery
Goetermann. . . . . . . . Berl. Klin. Wohnschr., Igo3, No. 28. . . . . . . . . P ? | Tropacocain. . P | Both ext, rect... . . . . . . . 8 ? . . . . . . . . .
Landow. . . . . . . . . . . . München. Med. Wohnschr., 1906. . . . . . . . . . . ? | ? | Novocain. . . . . P | Both ext, rect... . . . . . . . 7 ? . . . . . . . . . Recovery.
Mingazini. . . . . . . . . . Rev. Neurol., March 15, 1906. . . . . . . . . . . . . . 16 || M. Stovain. . . . . . . ? | Almost complete oph-
thalmoplegia externa. I3 * . . . . . . . . . P
Becker. . . . . . . . . . . . München. Med. WChnschr., 1906. . . . . . . . . . . ? | ? | Stovain. . . . . . 6 | Third nerve and sixth P P
IlêIVé. . . . . . . . . . . . . . . II ſ . . . . . . . . . e
Ach. . . . . . . . . . . . . . . München. Med. Wohnschr., Igo7. . . . . . . . . . . P P | Stovain . . . . . . . ? | One ext, rect... . . . . . . . . 8 21 days. . . . . Recovery.
Ach. . . . . . . . . . . . . . . München. Med. Wohnschr., 1907 . . . . . . . . . . . P ? | Stovain. . . . . . . ? | One ext, rect... . . . . . . . . 4. 43 days. . . . . Recovery.
Ach. . . . . . . . . . . . . . . München. Med. Wohnschr., 1907. . . . . . . . . . . P | ? | Stovain. . . . . . . ? | One ext, rect... . . . . . . . . II 6 days. . . . . Recovery.
Ach. . . . . . . . . . . . . . . München. Med. Wohnschr., 1907. . . . . . . . . . . ? | ? | Tropacocain. . . . P | One ext, rect... . . . . . . . . 7 8 days. . . . . Recovery.
Reber. . . . . . . . . . . . . Present report. . . . . . . . . . . . . . . . . . . . . . . . . . . 4o M. Stovain. . . . . . . 6} | Both ext, rect... . . . . . . . I 2 ?. . . . . . . . . Persisted at the time he left hospital.
Reber. . . . . . . . . . . . . Present report. . . . . . . . . . . . . . . . . . . . . . . . . . . 16 F. Stovain . . . . . . . 6} | Both ext, rect... . . . . . . . 8 weeks. 6 mos.. . . . . Palsy persisted.
Reber. . . . . . . . . . . . . Present report. . . . . . . . . . . . . . . . . . . . . . . . . . . 24 || M. Stovain. . . . . . . 6} | L: ext, rect. . . . . . . . . . . . 7 7 days. . . . . Recovery.
Reber. . . . . . . . . . . . . Present report. . . . . . . . . . . . . . . . . . . . . . . . . . . 35 | M. | Tropacocain. . . . 6; One ext, rect... . . . . . . . . IO I4 days. . . . . Recovery.
Reber. . . . . . . . . . . . . Present report. . . . . . . . . . . . . . . . . . . . . . . . . . . 19 F. Stovain. . . . . . . 6% | L. ext, rect. . . . . . . . . . . . 7 | f . . . . . . . . . Under observation only three days
at time of report.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 449
The possibility of hemorrhage being the cause has been advanced,
but has not met with much support. It was suggested that the
change in the cerebrospinal pressure acting upon diseased vessels
induced minute ruptures, but, if such were the case, we would most
likely have associated disturbances elsewhere with greater frequency
than they occur. -
The fact that these disturbances occur most often in high punctures
would suggest the direct action of the agents or toxic properties in-
duced by this preparation acting directly upon the nerves, or their
origin in the floor of the fourth ventricle; to act on the nerve-trunks
themselves would necessitate a much higher ascent of the drug and
most probably produce other disturbances. A special affinity or sus-
Ceptibility of these nerves or their centers must also be presumed.
This last view is concurred in by Dr. Babcock in a letter to Dr. Reber,
extracts from which I give below.
“There have now been given by Dr. Steele, Dr. Martin (and
his assistants), Dr. Applegate, and myself about 2000 injections for
the production of spinal analgesia. Personally, I have given about
I400 injections, having used stovain, tropacocain, eucain, cocain lac-
tate, novocain, and alypin. Most of the injections have been given
with Stovain or tropacocain. These analgesics have been given dis-
solved in water, with or without the addition of sodium chlorid, ad-
renalin, Io per cent. alcohol, or Strychnin. I have had great difficulty
in securing uniform solutions, although ampules of the Solution
have been prepared for us by German, French, and several American
chemists, and we have also prepared the Solutions extemporaneously.
All these local anesthetics seem to share with cocain, though perhaps
to a lesser degree, instability in the presence of heat, so that boiling
may set free certain undesirable and even toxic substances. I have
noticed the clinical evidence of this with cocain in decreased anes-
thetic action and severe pain after the injections of boiled Solutions
of this alkaloid for purposes of ordinary local anesthesia. I have seen
local necrosis follow the injection of stovain in strong Solution in the
prepuce. When used for spinal analgesia, boiled Stovain Solutions
give more frequent and more severe secondary headaches (and,
at times, even stiffness and rigidity of the muscles of the back of the
neck) than solutions which have not been exposed to high degrees
of heat. Moreover, the solutions which show the greatest untoward
after-effects seem to show a deficiency in analgesic power. Similar
observations have been made in reference to tropacocain.
“The interesting fact is that all of the 4 cases in which ocular
29
45O LOCAL ANESTHESIA
palsies have been noticed have occurred after injections for analgesia
of the lower abdominal segments.
“At the present time I would draw the following conclusions:
“I. We have no positive final proof that pure Stovain or tropacocain
when used for spinal analgesia will be followed by paralysis of the
ocular muscles. -
“2. The use of solutions of both stovain and tropacocain may
be followed by such palsies and by other symptoms suggesting the
presence of associated by-products.
“3. The palsy may occur irrespective of the use of adrenalin,
alcohol, glucose, or other admixture, although it is possible that
some of these substances may accentuate or favor the undesirable
effect. - -
“4. The antiseptic properties of stovain and tropacocain, and the
fact that in quite a number of instances I have withdrawn cerebro-
spinal fluid from one to many days after the spinal analgesia, and have
never found the slightest turbidity of cellular exudate or other indi-
cation of inflammatory action, inclines me to the belief that sepsis or
, a bacterial irritation is not responsible for the ocular palsy.
“5. An incidence of ocular palsy in I to 4oo or 5oo spinal anal-
gesias and the occurrence of frequent headaches should make sur-
geons very careful to avoid heated or decomposed solutions for spinal
analgesias.
“6. Spinal analgesia should not be discredited by the untoward
effects resulting from decomposition or contaminating by-products.
Unfortunately, no Squibb has yet arisen to do for spinal analgesics
what has been done for ether and chloroform.”
THE METHOD OF JONNESCO
Dr. Jonnesco first brought forward his method before the Inter-
national Society of Surgery in Brussels, Sept., 1908, when he reported
I4 cases. Since then he has repeatedly been in print, either alone or
with Dr. A. Jiano, writing on the same subject. For the most part,
his later articles have been in defense of his method or in reply to
criticisms.
The essentials of his injection consist of high punctures over the
spinal cord proper, and in the addition of Strychnin sulphate, which
he claims combats the bad effects. He writes as follows:
“There are two essential points of novelty in this method: (1)
The puncture is made at a line of the spinal column appropriate to
the region to be operated upon. (2) An anesthetic solution is used
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 45I
which, thanks to the addition of Strychnin, is tolerated by the high
nervous centers.”
He at first advocated four points of puncture—a mediocervical,
upper dorsal, mediodorsal, and dorsolumbar—but later has dropped
two, using only the upper dorsal, between the first and second dorsal
vertebrae, and dorsolumbar, between the twelfth dorsal and first lumbar.
The drug used has been principally stovain. The size of the dose,
as well as the dose of Strychnin used, varies with the point of puncture
and the age of the patient, using less in high punctures and in young
Subjects. The dose of Strychnin varies between .5 to I. mg. If it
were advisable to add strychnin it could be given beforehand, as is
Scopolamin and morphin. Dr. Fowler has recommended this, giv-
ing 1% gr. Strychnin hypodermically a quarter of an hour before the
puncture, but the procedure has not been generally adopted. In
administering such drugs as Strychnin, in direct contact with the
nervous system, their action is much more active than when adminis-
tered subcutaneously; but, as in the case of such drugs as strych-
nin, it would seem unnecessary to inject them into the canal. In
Spinal puncture our aim should be to simplify, as much as possible,
the anesthetic solution, and to add nothing to it not absolutely neces-
sary. Reports from surgeons who have witnessed Dr. Jonnesco's
injections in this country and abroad are, on the whole, condemnatory
of the method. In some the injections worked well, in others they were
complete or partial failures. Many were made quite ill, and some
barely escaped with their lives after heroic efforts at resuscitation.
The method, while possible, is fraught with too much danger, and,
from the humane standpoint, unjustifiable.
The necessity of practicing artificial respiration on conscious but
terrified patients, with paralyzed respiration, must be an experience
they can never forget.
In surgery of the upper parts of the body, when general anesthesia
is inadvisable, local or regional anesthesia can be used in a large
number of cases, and this number is steadily increasing with our
improvement in technic. Where high spinal anesthesia seems ad-
visable the method, as suggested by Barker, would seem preferable,
but it seems doubtful, even with this method, that analgesia will be
safe higher than the clavicles.
TREATMENT OF AFTER-EFFECTS
Slight headache, nausea, or temperature usually require no treat-
ment, passing off in a few hours to a day or two at most. The head-
452 LOCAL ANESTHESIA
ache may be verv severe, often unbearable, and may persist for a week
or longer. The usual headache remedies—ice-bag, aspirin, antipyrin,
phenacetin, codein, etc.—may be used and sometimes do good.
Nitroglycerin and amyl nitrate have been recommended and claimed
to benefit some cases, though it would seem, on theoretic grounds,
that if the headache is due to reactionary increase in intracranial ten-
sion or irritation they would be contra-indicated. Small doses of
atropin hypodermically have also been said to yield good results.
Several observers have reported benefit following tapping of the sub-
arachnoid space, allowing the escape of 5, Io, or I5 c.c. of cerebrospinal
fluid, which in these cases is said to be under much greater tension,
as evidenced by the way the fluid will flow from the needle, and is
often turbid. When this practice has been followed, the headache
has been much benefited or entirely disappears; some cases, where the
fluid has been turbid, have required tapping several times. The prac-
tice should be tried in severe cases that do not yield to other means.
Temperature, if sufficiently high or continuous, should be com-
bated by the usual means—sponging, wet back, or ice-water enemas.
Nausea or vomiting is not much benefited by remedies by the
mouth, as the trouble is central, but these may be tried, and some-
times seem to do good; washing the stomach may also be tried.
Keeping the patient perfectly quiet in bed, free from surrounding
disturbances and noises, is often of much benefit to the headache
and nausea; any movement on his part is often followed by an in-
crease in the headache or an attack of nausea.
Weak pulse or collapse, coming on after operation, is best met by
the usual remedies—caffein, oil of camphor, adrenalin solution, or
digitalin by needle. -
The after-vertigo seems to yield to full doses of strychnin kept up
for Some time, but it is often persistent and may last for several
weeks.
The numerous lesions and trophic disturbances should be treated
the same as those arising from other causes.
In the event of spinal meningitis developing as the result of a lum-
bar puncture, it has been suggested to irrigate the subarachnoid
Space by two punctures, one above the other below the area involved.
It is, however, not very likely that such a practice will do any mate-
rial good in a septic inflammation of the meninges. The irrigation
would no doubt have to be of limited duration and practiced only at
intervals. However, it is worth bearing the procedure in mind, as it
may prove of some value occasionally.
SPINAL ANALGESIA AND EPIDURAL INJECTIONS 453
EPIDURAL INJECTIONS
In connection with spinal analgesia should be considered the
epidural injections of Cathelin.
The dural sac ends opposite the third sacral segment. The remain-
ing space in the Sacral canal is filled with cellular tissue, and contains
nerve trunks which form the Sciatic and pelvic nerves, running from
the dural sac to the Sacral foramina. Cathelin conceived the idea of
medicating the nerves in this position for various pelvic neuroses,
especially neuralgias of the lower half of the trunk and incontinence of
urine. The method has lately been used during labor to anesthetize
the pelvic outlet; it has also been suggested for sexual neuroses.
The technic is as follows: With the patient lying on his abdomen
or side, the opening of the Sacral canal is sought for with the finger.
This is located just below the last sacral spine, just above the articu-
lation with the coccyx. The skin over this point is anesthetized with a
weak novocain solution, and a long needle is inserted into the opening
in the long axis of the bone and pushed up 1% or 2 inches until it is
well within the sacral canal, when the solution can be injected. This
may consist of plain water or salt Solution alone, or containing an appro-
priate quantity of cocain, novocain, codein, or morphin; 6 or 8 ounces
or more may be used. The method of its action is hard to explain,
but seems to be due to the physical interference, as well as such chemi-
cal changes that may be induced by bathing the nerves in this space
in the injected solution. Cathelin has personally had over Iooo cases
treated by this method, and his associates many more. The results
in incontinence of urine have been 49 per cent. cured, 35 per cent.
materially improved, and 4 per cent. failures. It may be necessary
to repeat the injection several times. There is usually no after-dis-
turbance, as the injection does not enter the subarachnoid space, but
it is extradural. The solution runs out of the many sacral canals,
much of it into the pelvis, bathing the nerves in their course through
these openings. A short rest in bed after the injection is the only
after-treatment necessary. In the hands of the writer this method
has given fairly good results. Its use as a means of anesthesia during
labor and for pelvic operations has not been satisfactory. It often fails
to produce the desired anesthesia. Its action is necessarily of limited
duration, and unless timed to meet the fetus in the lower pelvic outlet
would be of no assistance; however, some writers have used it and claim
fair results. It has been used for the low application of forceps and to
repair the perineum; it is, however, more used as a therapeutic than
as a surgical aid. (See Experiments on the Movements of Solutions
within the Epidural Space in chapter on Paravertebral Injections.)
CHAPTER XXI
PARAVERTEBRAL AND PARASACRAL ANESTHESIA
PARAVERTEBRAL ANESTHESIA
THE introduction of paravertebral anesthesia is quite a new depar-
ture among regional methods, and while even now beyond the experi-
mental stage, having been used successfully by a number of operators,
the method has not been sufficiently developed yet as a routine pro-
cedure, but when perfected may promise much for the future.
Undoubtedly the first attempt at a paravertebral injection was
by Corning in 1885, who attempted to inject an anesthetic solution in
close contact with the spinal cord by making a deep injection near
the vertebrae, these experiments were the beginning of spinal anes-
thesia. It is possible that he got within the membranes, though he
did not intend to.
The paravertebral methods of to-day were first conceived by
Sellheim, who in 1905 anesthetized the abdominal walls by an injec-
tion made around the roots of the eighth to twelfth dorsal, iliohypo-
gastric, and ilio-inguinal nerves.
The roots of the spinal nerves join within the intervertebral for-
amina, and immediately divide into anterior and posterior branches;
from the anterior branch a filament is given off, which runs forward to
communicate with the sympathetic system.
In making these paravertebral injections the object is to reach the
nerves at their point of division, so as to anesthetize this communica-
ting filament (Figs. 65, 73, 133).
From a study of the vertebral column of the average adult, with a
view of obtaining information for the guidance of paravertebral in-
jections, we find on its posterior aspect that if a vertical line is drawn
down the tips of the Spinous processes and lateral measurements
made from this line the free interval between the transverse pro-
cesses is about I inch on each side (Fig. 133). While the conformation
of the vertebrae in the dorsal and lumbar regions is quite different,
this measurement holds good along the entire dorsal and lumbar
regions. As the intervertebral foramina are shielded posteriorly by
the lateral projections of the articular processes, a point about # inch
454
D.
E. F.
MOTOR
DISTRIBUTION.
SENSORY REFLEXES,
AREAS.
NECK AND SCALP
NECK AND
fºLINOR. 7
BRACHIALIS,
BRACHIO-
8UPINATOR
... PRONATOR8.
MAJ. LAT188,
OF WRi8T.
OF THE
AND OTHER
MUSCLES OF
N
INTERCOSTAL
MUSCLE8.
\
|
ABDOMINAL
MUSCLES,
FLEXORS OF
OF KNEE &
OF THIGH.
HAMSTRING MUSCLE8.
PERONEI, ANTERFOR
OF LEG MUS-
INTRINSIC
OF FOOT.
PERINAEAL MUSCLES
FRONT OF
THORAX.
8CAPULAR
|
EPIGASTRIC e
jurº
º
UMBILICUS (10TH
A
|LiOHYPOGASTRIC AND
| LIO-INGUINAL..
PEN IS-TRANS.
ACCEL. URIN. &
AND RECT UM.
e
AND UPPER
THIGH,
ASPECT OF
BELOW SECOND
ROOT
AND INNER
OF LEG.
F THIGH,
IN DISTRIBUTION OF
, 2ND & 3RD
NARROW STRIP ON
BACK OF THIGH, LEG
AND ANKLE; 8OLE;
PART OF DORSUM OF -
CLONUS.
PERINAEUM, EXT.
SADDLE SHAPED PLANTAR.
OF BACK OF
k
of Anatomy.”)
Fig. 132-Topography and distribution of the spinal nerve-roots.
(Gerrish, “A Text-book

456 LOCAL ANESTHESIA
further out, making 1% inches from the midline, is best selected as the
point of puncture, so as to enable the needle to be directed upward
and inward toward the intervertebral foramina.
The average interval between the transverse processes in the dorsal
region is about ; inch, while the midpoint of this space lies in a vertical
line about 1 inch from the midpoint of the space above or below it.
In the lumbar region the free space between the transverse proc-
esses is from to # inch, and the distance from the midpoint of one
space to that of the other is about 1% inches.
On the lateral aspect we find that measurements made directly
inward, from a plane passing through the tips of the spinous processes,
reach the intervertebral foramina at a distance of about 1% inches
Fig. 133.-Posterior view of dorsal and lumbar spinal column with measurements for para-
vertebral injections. (See text.)
in the upper dorsal to about 1% inches in the lower dorsal and lumbar
regions. To this distance we should add + inch or more for soft parts,
according to the stoutness of the individual (Fig. 134). It is further
seen on the lateral view that the tips of the spinous processes in
the dorsal region considerably overlap the vertebra below, this
downward projection growing less in the lower region, so that no
reliable guide is offered by these processes for the location of the
space between the transverse processes; while in the lumbar region it
may be fairly accurately stated that the lower border of any transverse
process lies slightly below the level of the tip of the spinous process
of the same vertebra, and that a needle directed inward and upward
at the proper lateral position (1} inches from the midline) and about

PARAVERTEBRAL AND PARASACRAL ANESTHESIA 457
on a level with the middle of the spinous process should pass freely
between the transverse processes of that vertebra and the one above.
In the dorsal region, as we have no such guide, it is best to feel
for the intertransverse space, with the point of the needle directed
inward from a line 1% inches lateral from the tips of the spinous proc-
esses, and, having located this interval at any one point, the point
Fig. 134.—Lateral view of dorsal and lumbar spinal column with measurements. (See text.)
of puncture for the space above or below will be about 1 inch removed
on the lateral line.
These measurements were made on the vertebral columns of several
adult skeletons and utilized for verification on the cadaver, and,
while subject to small variations, will, I believe, be found fairly accu-
rate for the adult of average size.
Läwen, in 1911, performed a nephrotomy by blocking the intercos-
tal and three upper lumbar nerves.

458 LOCAL ANESTHESIA
The most noteworthy articles upon this subject to date have been
by Låwen, Kappis, Heile, Wilms, and Franke; but Finsterer's work
on this subject has been particularly thorough and comprehensive.
One and 1% per cent. solutions of novocain with adrenalin have
been the strength usually employed. The total quantity of novocain
used being o.4 to o.8 gm. Finsterer, in a case in which he used o.4 gm.,
injecting the eleventh and twelfth dorsal and first and second lumbar
nerves, reports that the duration of the anesthesia was two hours.
In extensive operations, where six or eight points are injected on
each side, using approximately 5 c.c. at each point, which, Com-
bined with the skin injections at the puncture points, brings the total
quantity of solution used up to 75 to Ioo c.c., which, if it be a I per
cent. solution, certainly would appear to exceed the safe limits of the
drug.
While no mishaps have occurred, some patients have shown
symptoms which have served as a warning note and has stimulated
animal experimentation to determine the best methods of procedure.
As some of the injected solution must reach the epidural space through
the spinal foramina, rather free epidural sacral injections were made
upon animals to study the movements of a definite quantity of Solution
injected within the epidural space.
Läwen and Gaza found with colored solutions plus adrenalin in
epidural sacral injections that the solution often ascended as far as
the lower portion of the thoracic cord, while Muroya, in a somewhat
similarly made injection, found that the ascent of the fluid was often
higher—to the cervical region and frequently into the skull.
The difference in the results obtained by these investigations may
be accounted for, as Muroya states, by the quantity of the solution
used and the pressure under which the injections are made. He,
accordingly, timed the rapidity of his injections and used Io c.c. per
kilogram of body-weight of the rabbit, of a colored 5 per cent. novo-
cain adrenalin solution, injecting I c.c. per minute, and found, as in
his previous experiments, that the solution ascended often as high
as the skull, and but seldom was found to stop at the middorsal
region.
Muroya found that in rabbits paravertebral injections are rela-
tively more toxic than subcutaneous; this may be explained in several
ways: (1) The solution may ascend to the higher centers through the
subdural space, or (2) the blood-vessels may more rapidly absorb it in
this position; (3) it may be rapidly taken up by the large network of
lymph-spaces which overlie the vertebral column, particularly in the
PARAVERTEBRAL AND PARASACRAL ANESTHESIA 459
abdominal cavity, as the colored solution has often been found in ani-
mals high up in the thoracic duct a few minutes after injection. This
absorption through the lymph-spaces seems the most probable.
A comparison made by Muroya with subcutaneous and paraver-
tebral injections of novocain colored with methylene-blue showed
methylene-blue in the urine, in ten to twenty minutes following sub-
Cutaneous injections, and in five to ten minutes following para-
vertebral. -
From the work of Muroya upon rabbits, he concluded that the
paravertebral injection is six times more toxic than the subcutaneous,
but that this toxicity can be greatly reduced, making it about equal
to the Subcutaneous injection, by combining 5 per cent. gelatin with
the adrenalin in normal salt solution, the adrenalin preventing or
delaying its absorption through the blood-vessels, while the gelatin
delays its diffusion into the cellular lymph-spaces.
By the use of this mixture its action at the point of injection is in-
tensified, as the solution is more or less retained at the point of in-
jection.
In drawing positive conclusions from the above it must be remem-
bered that it is not always safe to apply the results of animal experi-
mentation to man. In the first place the formation of the sacral
canal may not exactly correspond to that of man, where the numerous
large foramina for the exit of nerve-trunks permit any injected solution
to readily escape in all directions, and besides the difference in the dis-
tance between the sacrum and skull in the rabbit and in man is consid-
erable. These experiments are, however, more valuable for determining
the movements of the injected fluid in epidural (sacral) injections.
Kappis has reported paravertebral injections of the cervical region.
A line on either side of the spinous processes was anesthetized, and a
long needle advanced forward until the transverse process was en-
countered. The interval between these processes is sought for by the
point of the needle, which is advanced from I to 1% cm. further and
the injection made.
Kappis used 1% per cent. novocain-suprarenin solution. The per-
formance of paravertebral injections in such regions as the neck must
receive further experimental study before it can be popularized; the
likelihood of the solution reaching the phrenic nerve in effective
quantity should not be lost sight of; its origin from the third, fourth,
and fifth cervical is practically the center of the field, and after forma-
tion its course is more superficial. If the solution is effectively used
this nerve should be paralyzed; however, unless the procedure is car-
460 LOCAL ANESTHESIA
ried out on both sides, the temporary one-sided paralysis is not likely
to be of consequence.
The paravertebral injection of the cervical region is carried out
by Braun in a somewhat different way, following the suggestion of
Heidenhain.
The injections are made from the side, between the third and fifth
vertebrae, rather freely with a o.5o per cent. novocain-adrenalin solu-
tion at the point where the nerves lie rather close together. A line
is drawn on the neck from the transverse process of the atlas, which
Fig. 135-a and b, points of injection on line drawn over transverse processes of cervical
vertebrae. (From Braun.)
is felt under the point of the mastoid process downward over the trans-
verse process of the sixth cervical vertebra (tuberculum carotidum).
This line represents the point at which the long axis of the trans-
verse processes reach the surface, and forms a sharp angle with the
edge of the sternomastoid as it gradually draws away from this muscle
(Fig. 135).
Two points of puncture are made on this line—the upper one
on a level with the lower border of the inferior maxilla, the lower one
on a level with the promontory of the larynx.
From these two points of puncture the needle is carried directly
inward, until it comes in contact with the transverse processes of the

PARAVERTEBRAL AND PARASACRAL ANESTHESIA 461
vertebra, injecting freely in the interval between the two points of
puncture by injections made deep down, in a fan-like manner, using in
all about 30 to 40 c.c. of a per cent. novocain-adrenalin solution.
The great vessels of the neck are in no danger, as they lie somewhat in
front of this line.
For operations on the midline of the neck both sides are injected,
and where it involves the larynx the superior laryngeal is blocked in
addition, as described in the chapter on the neck, and if the field of
operation extend to the base of the lower jaw the third division of the
fifth nerve is also blocked.
Fig. 136. Fig. 137.
Figs. 136, 137.-Points of injection for paravertebral anesthesia for kidney operations,
showing area of resulting anesthesia. (From Braun.)
Braun states that this method produces an effective surgical anes-
thesia for all major operations in this region.
Braun has performed three nephrotomies by paravertebral methods,
and made accurate observations of the extent of the field of anesthesia.
The eighth to the twelfth dorsal nerves were injected each with
5 c.c. of a 1 per cent, solution; the line of puncture lay on a line which
corresponded to the upward extension of the outer margin of the
quadratus lumborum.
A point of anesthesia was now established over the crest of the
ilium at the outer border of the quadratus lumborum; between this

462 LOCAL ANESTHESIA
point and the point of puncture for the twelfth dorsal nerve was a
rather free and deep injection made down to and including the fatty
tissue around the kidney, using for this purpose 75 c.c. of a o.5o per
cent. novocain-suprarenin Solution. The points of injection and
distribution of anesthesia are shown in Figs. I36 and I37.
Braun States that the entire procedure was painless, including the
luxation of the kidney, and while his patients were thin he believes
that the anesthesia of this region by local methods has been conquered.
Finsterer, who has employed this method for 6 laparotomies and
other major operations, gives his technic as follows:
The spine of the first lumbar vertebra is located, and a point on
the skin from 3 to 3% cm. laterally is anesthetized; the needle marked
in centimeters is passed vertically inward through this anesthetized
point to a depth of from 4 to 5 cm., according to the stoutness of the
individual, until the transverse process is struck; the upper border
of the process is then felt for with the needle; when this point is
reached the syringe is carried outward and downward, directing the
needle-point upward and inward, when it is advanced about # to I
cm. further, and 5 c.c. of a I per cent. Solution of novocain adrenalin
is then injected in a fan-shaped area. Care should be exercised not
to push the needle too deeply, as the anesthetizing fluid will pass be-
yond the ganglion and be useless.
The points for reaching the first, second, and third lumbar nerves
will be at intervals of 3% to 4 cm. from each other, according to the size
of the individual.
PARASACRAL ANESTHESIA
The anterior surface of the sacrum shows that the anterior sacral
foramina lie almost always in a straight line, which from below up has
a slightly outward angle. The distance between the midpoint of the
first sacral foramina is 1% inches, and between the midpoint of the fourth
is 1% inches (the fifth sacral foramen is formed by articulation with the
coccyx, and does not appear as a separate opening), so that if a line is
drawn down the midline of the sacrum a line running over the center of
the foramina diverges but ; inch from the midline in passing upward
from the fourth to the first foramina.
The distance from the free margin of the sacrum at its lower free
border (sacrococcygeal junction) along the line passing over the center
of the foramina is # inch to the midpoint of the fourth foramen, 1%
inches to the midpoint of the third foramen, 2% inches to the midpoint
of the second foramen, and 3% inches to the midpoint of the first sacral
PARAVERTEBRAL AND PARASACRAL ANESTHESIA 463
foramen. This then makes the foramina the following distances
apart: approximately £ inch from the fourth to the third and from
the third to the second, and the first is I inch from the second
(Fig. 138).
On the lateral view it is seen that if the needle is passed straight
in over the lower free margin of the sacrum # inch from the midline,
and directed upward almost in a straight line, with a very slight out-
ward inclination, that it will pass directly over the fourth, third, and
Fig. 138-Anterior view of sacrum, slightly reduced, showing relative distances to foramen.
second foramina, when, after meeting the bone above this opening,
if it will be slightly withdrawn and redirected, with the point elevated
# inch and advanced 1 inch further, that it will reach the first sacral
foramina (Figs. 139, 140).
It is seen, after a study of numerous sacrums, that the intermediate
foramina between the fourth and first in some few are placed somewhat
outside of the straight line, passing over the center of the openings;
this lateral variation is usually about $ inch, and was never seen to
exceed # inch.

464 LOCAL ANESTHESIA
As the nerves, as they emerge from the foramina run downward,
outward, and forward (Fig. 141), it would seem best to slightly increase
Fig. 139.-Distances and relative position of foramen on lateral view of sacrum.
Fig. 14o.—Direction of long needle for parasacral injections. (From Braun.)
the lateral angle of the needle, so that at a depth of about 2 inches its
point will be about 4 inch lateral to the point of entrance; in this way


PARAVERTEBRAL AND PARASACRAL ANESTHESIA 465
lateral sacral artery
lumbosacral trunk
inf mesenteric arter.
aortic bifurcation
left common iliac artery x-
left common iliar vein x-
*~ superior gluteal art.
right common iliar artery
sacral nerve 1
middle sacral art.
right hypogastric art.
right iliolumbar art. "
sacral plexus
sarral gangſta
of sympath.
trunk
right external iliac art.
umbilical artery x.
inferior
gluteal art.
obturator art.
obturator nerve
-
ext, spermatic
- rter-e
ext spermatic * ,
artery -
-
sacral
| \ nerve III
sarr, nerves IV and V.
\ | º \ middle haemorrhoidal
º i. sº rves
l | * Coccygeus \ corrygeal nerve
- -
l . *crospin. ºpudendal plexus
- :- ig. x
º i
bic and obt branch | :
pubic and obturator branches . . .interpabic : ,
of inf. rpigastric art. -interpubic
internal pudic art. x
- - Obturnt, innº-
fibrocartil, pubic ºr of
inf. roigastric art.
middle haemorrhoidal art. x
obturat, art.
pudic nerve
infer, vesical art.
Fig. 141.-The blood-vessels and nerves on the right pelvic wall. The pelvis has been
halved by a sagittal section and the genitalia removed. X= Branches to the coccygeus.
XX = Branch to levator ani.
+ = Site of abdominal inguinal ring. ++ = Branches
to pyriformis. (Sobotta and McMurrich.)
the needle cannot go astray, and may even transfix these nerves
though the foramina do not lie in a straight line.
SACRAL ANESTHESIA
This is made, according to Braun, as follows: With the breech of
the patient well presented, the long fine needle (for this purpose it
should be about 5 or 6 inches long) is entered about 1% or 2 cm. from

























30
466 LOCAL ANESTHESIA
the middle line, on a level with the sacrococcygeal joint. As the inner
surface of the sacrum up to about the second foramina is but little
curved, the needle is advanced straight up from the point of puncture,
in close contact with the bone, until it impinges with it near the second
sacral foramina; this point is about 6 to 7 cm. from the point of
puncture at the sacrococcygeal joint in the adult, not counting the
thickness of the soft parts.
One proceeds in the following manner: The needle is entered on
the inner surface of the lower border of the sacrum and directed upward
in a parallel direction seeking for the edge of the bone; the needle is
then pushed along the inner surface, parallel with the middle line, un-
til it reaches the bone at about the recognized depth; along the entire
way, from the second to the fifth sacral foramina, 20 c.c. of I per cent.
novocain-adrenalin solution is injected. The injections should not be
made except when the needle is in contact with the bone. The needle
is now drawn back to the edge of the bone and redirected at a slightly
increased angle, but still parallel to the middle line toward the linea
innominata; reaching the bone just above the first sacral foramina,
about 9 or Io cm. from the point of entrance (not including the soft
parts), 20 c.c. of the I per cent. Solution are injected here.
Before finally withdrawing the needle 5 c.c. are injected between
the coccyx and rectum. The same procedure is repeated on the op-
posite side, using in all about Ioo c.c. of solution. Braun states that
there is no danger of injuring the rectum if empty, as it is pushed out
of the way by the advancing needle, but a finger may be inserted within
it if preferred for guidance.
This method produces an effective means of anesthesia for such
operations as prostatectomy, prolapse of the uterus, and resections
of the rectum, as well as other minor operations upon these parts, but
it is not sufficient for a total hysterectomy, as here the upper part of
the field is not reached by the pelvic nerves. *
CHAPTER XXII
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE
“THE application of local infiltration and regional anesthesia to
the major Surgery of these parts is greatly hampered and hindered, in
the hands of the average operator, by the difficulty of effectively reach-
ing the most important nerve-trunks and by the inability to control
the circulation except in a few favorable areas. Nevertheless, sur-
prisingly brilliant results have been obtained with these methods by
those who are adepts in their application, and who are alert for op-
portunities to substitute them for general narcosis. At one time it
was thought that the head and face were particularly dangerous re-
gions in the practice of cocain operations, and that extensive infiltra-
tions with the drug were to be avoided on account of the close proxim-
ity of these parts to the brain and medullary centers. The evil
repute of cocain in head surgery was traceable to the numerous acci-
dents and fatalities which occurred in the earlier days of cocain anes-
thesia. In the hands of irresponsible or careless practitioners and
others—dentists and specialists in rhinopharyngolaryngeal practice—
toxic doses of appalling strength (Io to 20 and 30 per cent.), for the
extraction of teeth or in securing the anesthesia of the upper air-pas-
sage, were frequently resorted to. Reclus, in his careful and masterly
analysis of the mortality reports attributed to cocain in surgical
practice, completely disposes of this alleged “danger zone' of the head
by conclusively showing that in each case in which death or alarm-
ing symptoms occurred the accidents could always be traced to over-
dosing with unnecessary toxic solutions. In this way he has rendered
an inestimable service to the cause of local anesthesia. In conse-
quence of the use of the stronger solutions of cocain, which were
thought necessary in the earlier days of cocain anesthesia, the control
of the circulation was a matter of far greater concern than it is at
present, since the infiltration of weak solutions and a better knowledge
of the possibility of the neural method have been more clearly recog-
nized, and the introduction of the suprarenal preparations have
added these valuable aids to our armamentarium, both for the control
of hemorrhage as well as for prolonging and intensifying the anesthetic
action.
467
468 LOCAL ANESTHESIA
“At present the control of the circulation is still desirable, not so
much to diminish the dangers of intoxication, but to prolong and in-
tensify the action of this narcotic drug in long operations. The
demand for appliances to incarcerate the anesthetic’ is shown by the
invention of numerous devices, such as Corning's Scalp rings, Corn-
ing's hemostatic fenestrated forceps for operations on the cheek,
mouth, and breast, Noyes' ectropion forceps, Wright's clamp, etc.
At present the introduction of Schleich's infiltration anesthesia has
made these devices unnecessary, except in regions in which the ana-
tomic configuration of the parts (scalp and auricle) will permit of
easy elastic constriction, which is always advantageous if only from
the hemostatic point of view” (Matas). -
The surgery of the head with regional methods of anesthesia is
one of the most attractive and fascinating in the entire body, and its
operative procedure among the most brilliant in the entire domain
of surgery. In itself a vast field for the application of intra- and
paraneural methods, presenting an intricate labyrinth of foramina,
canals, fissures, and tracts for the passage of the great nerve-trunks and
their branches, always appearing in a new and interesting light, due
to the many brilliant minds that have made this region a field of
study, and have evolved new ways and means of access and approach
to the great nerve-trunks at their basal foramina and even their injec-
tion within the skull.
In this vast field the work is of interest alike to physician and
surgeon—to one for the alcoholization of the great nerve-trunks for
the relief of neuralgia; to the other, for the purpose of regional anes-
thesia of the peripheral parts, as well as for the deep injections of
alcohol, which, in its clinical application, should always be regarded
as a surgical procedure. Whether devised originally for the thera-
peutic application of alcohol or the proximal cocainization of the nerve-
trunks, both alike serve the same end in offering an approach to the
nerve-trunks and can alike be used for both purposes.
From the earlier pioneer efforts in this direction to the present time
are to be found a galaxy of brilliant names—Matas, Schlösser, Ostwalt,
Hecht, Lowenstein, Killiani, Patrick, Bodine, Keller, Wright, Harris,
Braun, Levy, Baudoin, Brissaud, Sicard, Taptas, and more recently
Offerhaus, and particularly Härtel, in his latest approach to the gas-
Serian ganglion and exhaustive presentation of this subject. -
In originally undertaking this work I had hoped that at least this
chapter would be from the pen of my distinguished chief, Professor
Matas, an original worker in this as well as other fields, and whose
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 469
brilliant achievements already fill many pages in the annals of
Surgery.
While deprived, at least for the present, of this benefit due to the
press of other matters, we may hope that should this chapter be re-
written it may come from his pen, and I hope that in this, as in
º º
%. \ &
To ciliary muscle 3°
* and iris. ! § *
+...º.º. ***),
ganglion. E.3% - 2
.. sº => 4.
22. 9.
& A .#
-traºr = #3
*:
Zoo, º- §§
& º-º-º:
&n. §§
-" cº º
-º-º: £,
22-s:
as
ºf Sºssº" . - Long ciliary. alſº 2% iſ º
...tº Twº Pººl
3. ==gland.
§ 2"
• 2:s 3. 4” - - Tºp
: • 2. gº 22* of noses.
§ 3. ….”º *oes.
º º ãº: 3.
- §3. Tº To temple,
Q gº --
\ - * & ~ -----
† ~ *z, -- k
} == % *** * To cheek. º
TS * Palpebral'ſ
t ~! s |
t § S
! § ! $ osſerior 32.
: ; ; $ $/ g 3.:
# / Yº 3.
i S. \\ -
# iſ
** Sº
; § L § { | N.
33 jā; "| | Ç. §
#3 ; ſ \ }
ºš tº
*3 & &
5 s | S.
# | §.
£&
She.sº & # * - s : -
ſº #, tº';" |\; K- wº
g j \, cº
f *
%
*
#
†:
*
i
§ SN V. §
* º & y
t *\Sub-maxillary W
& *º-º)" anºtion.
-on faciul artery.
*
to 9
Žºs
~. ºf -º-º-º: – ore. Widź
_*= *Avr *io. sº- (p.
>ssºo, *oto S. º
Og: OtoAğ. &e g
sºs “y.
Fig. 142–Diagram of the fifth cranial nerve. (From Flower.)
other chapters of this work in which I have so freely borrowed from
his knowledge, I may in some small measure reflect credit upon his
teachings. -
A few of the original illustrations in this chapter are from the
private collection of Prof. Matas, kindly loaned for this purpose and





























47o LOCAL ANESTHESIA
appear for the first time in these pages. These illustrations were pre-
pared by my colleague, Dr. Urban Maes, who, in association with
Prof. Matas, has done much work and developed great skill in this
field.
*e and stomoses between the branrhºs of the
- - Trigeminus and the
ferriral nerves
arietal br. of superf zºº -
p tempor. Z: º, -º - - - -- - Ars. of supraorbital nerve
- - - - *A fronfat br; of superf.
- - emporal art.
brs. of zygomatino-
femporal nerve
_Frontalis
zygonafiro-orbital art.
supraorbital art.
ſº frontal nerve
ºfrontal art.
gºt supraorbital nerve
edia/ palpebral art.
branches of º
origitaſ,’|
artery \
A. l.
| ºAnastonesis
Tºdorsal artery of nose
branches of infrarrorhear nerve
ranches º | Tzveomation-ſurial nerve”
great arripital *-* º # nasal br. of ant.
--ethmoid, nerve
ºan...")
Orripitalis angular art.
superf temporar \ - infraorbital art.
brs of anriruſo--A
temporal nerve
perfor, br. ºf post.
auricul, art. .
auricular br. of vagus.- W
temporal br. of farial nerve- º -
transverse facial art. º
zygomatic branch of . º - - -
farial nerve W Nº ---
º N º
lesserotripital nerve- N º º - - |
º º \ A º
º º
º \\ º sº
{\º
º
* nasal hrs. of
-------" ºr infraorb. nerve
- ºnfraorbi-
ºf nerve
ºbial brs of infra-
- orbital nerve
|
parotid plexus A * º *Tº º º
affariaſ nerve * * - Wºº N º º
parotid gland 2’ - \\ W º - -º
great auriculary.” 2' > W W º º
rter ºr x º A.-- º º -
- - - - hurringfor nerve
- * ºnental rferºe
burrn! branch N2 _* º
urra! branches A& º - *
- ---. mental artery
of facial nerve \ . Zºº. ... inferior labial art.
Massrfrn A - A -- Triangularis X
- external maxillary art.
-
posterior facial vein,'
\marginal mandibular br.
--
Sternor'eidomastoideus/~ -
,” of facial nerve
Platysma ,’
cervical br. of facial nerve --- * anterior facial vein x
Fig. 143–Superficial nerves and arteries of the face (deeper layer). Most of the
parotid gland is removed. The facial muscles have been cut away, divided, or drawn
downward. (Sobotta and McMurrich.)
For a thorough understanding of the methods of local and regional
anesthesia applied to the head a thorough knowledge of anatomy is
essential, with a study of the subject from every view-point; only then
can we properly appreciate the difficulties and delicate technic neces-
sary for the clinical application of these methods.


























THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 47I
The Fifth Nerve and Its Branches (Figs. 142, 143).-The ophthal-
mic or first division of the fifth (Fig. 144) is a sensory nerve, supplying
the eyeball, mucous lining of the eye, lacrimal gland, nasal fossa, the
- 2 supraorbital art.
**- supraorbital nerve
- …Levator palp. superioris
verſus superior
, lachrymal gland
supratrochlear-
nerve -
fant, meningeal
art.)
(ant, ethmoi-1 - -
dal art.) || 2:
Obliquus *
superior
nasoriliary
nerve
ophthalmirº
art.
* Alachrymal
* gland
- º lathrymal
N artery
-
tº abdurens
- nerve
- - |
Nº. - middle meningeal
sº- N -
trochlear nerve
frontal br. of
ophthalmic nerve
Iachrymal nerveſ
ophthalmicº -
nerve -
optic for."
optic nerver
- nerve
ophthalmic art. --
maxillary
- merve
\middle meningeal
- artery
inf. rarotid
art.
orulomofor º 77. A // - Nº. Nº.
- º V -
nerve
* nerve -
frochlear in ~spinous
mandibular
- - nerve -
S semilunar ganglion
^
abducens nerve.
rentorial nerve
trigeminal nerve
Fig. 144.—The nerves and arteries of the orbit (superficial layer). The roof of the
orbit, the periorbita, and the upper portion of the outer wall have been removed. The
dura mater has been divided along the middle meningeal artery and in the neighborhood
of the semilunar ganglion and of the orbital nerves. *= Accessory vessels to the lacrimal
gland from the zygomatico-orbital branch of the anterior deep temporal artery. **=Or-
bital fat. (Sobotta and McMurrich.)
skin of the nose, forehead, and front portion of the vertex. After
leaving the gasserian ganglion it passes forward along the outer wall
of the cavernous sinus, below the other nerves, which pass here (Fig.
21o), and just before entering the orbit through the sphenoidal fissure


























472 LOCAL ANESTHESIA
divides into lacrimal frontal and nasal branches. The lacrimal
branch passes forward in a separate tube of dura mater, and enters
the orbit at the narrowest part of the sphenoidal fissure (Fig. 164);
it then runs obliquely forward and outward above the upper border
of the external rectus to the lacrimal gland.
The frontal, the largest division of the ophthalmic, appears as a
direct continuation of this nerve. It enters the orbit above the
muscles through the highest and broadest part of the sphenoidal
fissure, and continues forward in the midline between the levator
palpebrae and the periosteum to about the middle of the orbit, where
it divides into supratrochlear and supraorbital branches.
The supratrochlear (Fig. 143) escapes from the orbit between the
pulley of the superior oblique and the supraorbital foramen; it curves
up on the forehead, close to the bone, beneath the occipitofrontalis
muscle, and is distributed to the skin of the forehead on either side
of the middle line. -
The supra-orbital nerve passes forward through the supra-orbital
foramen, supplies the upper eyelid, and ascends beneath the occipito-
frontalis muscle, and is distributed to the scalp and pericranium as
far back as the parietal and occipital bones. -
The nasal nerve enters the orbit between the two heads of the
external rectus, passing between the two divisions of the third nerve,
runs obliquely inward above the optic nerve, beneath the superior
oblique and superior rectus muscles to the inner wall of the orbit,
where it passes through the anterior ethmoidal foramen, giving off its
infratrochlear branch here, and enters the cavity of the cranium, where
it traverses a groove on the cribriform plate of the ethmoid bone and
passes down through the slit on the side of the crista galli into the nose.
Within the nasal cavity this nerve supplies the mucous membrane
in its upper and anterior parts. The nerve then descends in a grove
on the back part of the nasal bone, escaping between the lower border
of this bone and the upper lateral cartilage to supply the end of the
IlOS62.
Its infratrochlear branch supplies the skin at the inner angle of
the lids and side of the nose.
The superior maxillary nerve (Fig. 145) passes forward through the
foramen rotundum into the Sphenomaxillary fossa, passing obliquely
forward and outward. It enters the orbit through the sphenomaxil-
lary fissures, and passes into the infra-orbital canal and appears upon
the face at the infra-orbital foramen, where it divides into three sets
of branches—palpebral, nasal, and labial—which are distributed to
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 473
these respective parts (Fig. 143). In the sphenomaxillary fossa this
nerve gives off its temporomalar, sphenopalatine, and posterior superior
dental branches.
The temporomalar branch enters the orbit, and divides at the back
part of this cavity into temporal and malar branches. The temporal
Fig. 145–Innervation of the teeth (modified from Spalteholz). The outer wall of
orbit and part of the outer wall of superior and inferior maxillae have been removed: 1, In-
fra-orbital nerve; 2, 3, and 4, posterior, middle, and anterior superior dental nerves; 5,
sphenopalatine ganglion and nerves; 6, lateral mucous membrane, antrum of Highmore;
7, inferior dental nerve; 8, mental nerve. (From Braun.)
branch passes through a foramen in the malar bone and enters the
anterior part of the temporal fossa; it ascends between the bone and
substance of the temporal muscle, piercing the muscle and temporal
fascia about 1 inch above the zygoma, to be distributed to the skin
of the temporal regions and side of forehead. The malar branch

474 LOCAL ANESTHESIA
passes through a foramen in the malar bone, and appears upon the
cheek at the opening of this canal (Fig. 143), on the anterior surface
of the bone, about ; inch below the rim of the orbital fossa, where it is
distributed to the skin of the cheek.
The sphenopalatine descends to this ganglion, which lies just
below the trunk of this nerve in the Sphenomaxillary fossa.
The posterior superior dental branches are given off from the Superior
maxillary nerve in the sphenomaxillary fossa, just as it is about to enter
the orbit; these nerves pass down over the tuberosity of the Superior
maxillary bone to enter the dental canals on the posterior surface of
this bone about its middle; these nerves supply the three molar teeth.
The middle and anterior superior dental nerves are given off in the
infra-orbital canal, the middle supplying the two bicuspids, the anterior
branch the canine and incisor teeth.
The descending or palatine branches from the sphenopalatine
ganglion are three in number—anterior, middle, and posterior. The
anterior descends through the posterior or palatine canal to appear
upon the hard palate at the posterior palatine foramen; it then passes
forward in a grove at the junction of the hard palate and alveolar
process, nearly as far as the incisor teeth, supplying the parts in the
vicinity of its distribution. In the palatine canal it gives off branches
to the nasal fossa. The middle and posterior branches are distributed
to the soft palate and tonsillar regions. -
The nasopalatine nerve is the only other nerve from the sphenopala-
tine ganglion which is of special interest. It enters the nasal fossa
through the sphenopalatine foramen, passes inward across the roof
of the nasal fossa to reach the septum, down which it runs to the
anterior palatine foramen, and appears at the opening of this canal
on the roof of the mouth to supply the surrounding soft parts.
The inferior maxillary nerve, largest division of the fifth, passes
through the foramen ovale and divides into two trunks—anterior
and posterior. It is joined at this point by its motor root, most of
which passes into its anterior division, which divides into masseteric,
buccal, and pterygoid branches, to be distributed to these muscles,
the masseteric passing through the sigmoid notch to reach this muscle;
the buccal branch, in addition to supplying this muscle, is distributed
to the skin of the cheek as far forward as the angle of the mouth.
The deep temporal branches, given off just after the nerve emerges
from the skull and running outward and upward, are distributed to
the temporal muscle. -
The auriculotemporal nerve curves upward with the temporal artery,
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 475
between the external ear and condyle of the jaw, beneath the sub-
stance of the parotid gland, and, passing over the zygoma, divides
into branches—auricular, Superior, and inferior, and a branch to the
meatus auditorius, which are distributed to these parts. The tem-
poral branches pass upward with the temporal artery and supply the
Scalp as far as the vertex of the skull.
The lingual nerve reaches the inner side of the ramus of the jaw,
down which it descends on the inner side of the dental nerve to the
base of the tongue, crossing obliquely forward and inward to this
organ, running along its side as far as the tip. Where the nerve
passes from the ramus of the jaw to the base of the tongue it is quite
Superficially situated beneath the mucous membrane, and is quite
easily reached in this position, particularly if the tongue is drawn for-
ward and to the opposite side.
The inferior dental nerve passes obliquely downward, forward, and
outward with the inferior dental artery to reach the dental foramen on
the inner side of the inferior maxilla. In the dental canal it gives off
branches which supply the teeth, and a mental branch, which appears
at the mental foramen and supplies the lower lip and the soft parts
of the chin.
In addition to the branches of the fifth the lower part of the face
receives branches from the cervical nerves. The side of the head
receives the auricular branch of the pneumogastric, which passes up-
ward between the mastoid process and external auditory meatus to
the back of the ear. The occipital region is supplied by the occipitalis
major and minor and the auricularis magnus. These nerves will be
spoken of in dealing with their areas of distribution.
Anesthesia.-To anesthetize the supra-orbital and supratrochlear
nerves an injection of about 2 drams of solution No. 2, o.5o per cent.
novocain, and a few drops of adrenalin to the ounce should be made
just over the supra-orbital notch, beneath the deep frontal fascia,
transversely for about I inch; or, where both nerves are to be in-
jected, this can be done by a subfascial injection, extending across the
base of the forehead, as indicated in Fig. 146, the shaded portion
indicating the anesthetic area; on the margins of this area for Some
distance back there is lessened sensibility. While it is quite feasible
to practice strictly regional anesthesia for the entire Scalp by blocking
the supra-orbital nerves in front, the occipital nerves behind, and the
temporal nerves on the side by a line of anesthesia just above the
zygoma, extending from the ear to the angle of the orbit and carried
down to beneath the temporal fascia, thus rendering the entire Scalp
476 LOCAL ANESTHESIA
anesthetic. This procedure limited to one side produces an anesthesia
reaching almost to the vertex, where the nerves of the opposite side
lap over. Such an extensive area of anesthesia is, however, not often
called for, while those parts supplied by the supra-orbital and occip-
- - - - -
Fig. 146.-Resulting area of anesthesia after blocking supra-orbital and supratrochlear
nerves along heavily shaded line. (From Braun.)
ital nerves will more often be found quite useful, easily and quickly
carried out; but where the field of operation is more or less central
on the scalp, it will, however, usually be found simpler and require less
solution to surround the operative area by a wall of anesthesia carried
Fig. 147-Surrounding tumor of the scalp with zone of anesthesia. (From Braun.)
well down to the pericranium, which will meet and anesthetize all
nerves entering the area and permit any contemplated operation upon
the soft parts, as well as resections of the bone and operations upon
the underlying dura and brain (Figs. 147, 148).


THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 477
Here the operative field is surrounded by an area of anesthesia,
and at several points along this surrounding zone the long needle is
entered and passed down to the bone through the points indicated
by the heavy dots, injecting the solution as the needle is advanced.
However, it is to be recommended, as a general rule, that all
extensive operations upon the soft parts or underlying bone in the
region supplied by the fifth nerve be operated by injections of ganglion
gasseri, or its nerves at their foramina of exit; the injection of the gan-
glion has the advantage that it anesthetizes the dura through its men-
ingeal branches as well as the overlying bone and soft parts.
Fig. 148.-Surrounding a compound fracture of skull with zone of anesthesia. (From
Braun.)
As the occipital nerves are several in number, and reach the scalp
at different points, they may be dealt with collectively. If a line of
anesthesia (solution No. 2, with 5 drops adrenalin to the ounce) is
produced, extending from ear to ear across the base of the mastoid
processes, and carried well down to the deep tissues, it will block all
branches of the occipital nerves, as well as branches from the auricularis
magnus, and result in an anesthetic area, as indicated in Fig. 149 (the
white line shows the line of infiltration), or the nerves may be dealt
with more or less individually in the following way:
The occipitalis major and minor and the auricularis magnus may

478 LOCAL ANESTHESIA
be blocked by making injections at their points of emergence at the
occiput (Fig. 150); the occipitalis minor and auricularis magnus behind
great occipital nerve
Occipitalis
occipital vessels occipital artery
great occipital nerve
occipital vein
lesser occipital nerve
orcipital br. of post
auricular art.
meningeal br.
of :::::::: art. grent auricular nerve
- - _ Splenius ropitis
occipital art. ... " Sternor leidomastoideus
descending br. of occipital art. z' º,
Semispinalis capitis
lesser-orripital nerve ~
Longissimus cap-
acressory nerve
*xternal jugular vein
dorsal rutaneous branches
º of rerwiral nerves
descend, br. of transv. cervical art. Levatorscapuldex'ſ
descend. br. of transw. cerviral vein dorsal seanu-
lar merre
Trapezius
-
Trapezius ×
peltoideº
Rhomboiden-
- minor x |
Teres major
Rhomboideus,
major -
Lafissimtits.
dorsi
posterior cutaneous branches of intercostal neries.
Fig. 149–The superficial and middle layer of the nerves and vessels of the nuchal
region. Upon the left side the trapezius, sternocleidomastoideus, splenius, and levator
scapulae have been divided. *=Occipital root of external jugular vein. (Sobotta and
McMurrich.)
the posterior margin of the insertion of the sternocleidomastoid. The
occipitalis major emerges upon the surface of the occiput through a














THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 479
cleft in the trapezius muscle, along with the occipital artery, the third
occipital, sometimes an independent nerve, passing slightly nearer
the midline; to reach both of these nerves a deep line of infiltration can
be carried from the posterior occipital protuberance one-third of the
distance toward the auricle. As emphasized by Härtel, and referred
to by Bier and Krause, in intracranial operations regional methods of
anesthesia should be preferred to infiltration around the operative
area in such operations where the electric excitability of the cerebral
cortex should not be disturbed, as in operations for epilepsy. When
performing such operations under infiltration anesthesia the diffusion
of the anesthesia may reach the cerebral cortex and interfere with
C C
&
C
8
S&S
&
2.
Ç
&
&
SXXº
S&
Fº
Fig. 15o.—Line of subcutaneous infiltration blocking occipital and auricularis magnus
nerves and resulting area of anesthesia.
electric tests. It must be remembered that here as elsewhere bone is
insensitive to pain after the periosteum has been anesthetized or
denuded, and it can be freely operated upon with trephine, chisel,
rongeur, or saw without the least discomfort, beyond the fact that
the patient hears and feels the jar of the manipulations. The dura is
insensitive to wounds inflicted through incisions or the application of
forceps, but is sensitive to traction should it be pulled upon, conse-
quently it can be freely incised and turned back without pain. This
statement holds good for the vertex and lateral surfaces of the brain,
the areas most frequently operated upon; however, at the base of the
skull, where the dura is attached to the bone, some painful sensations

48o LOCAL ANESTHESIA
are experienced, requiring infiltration of the dura here to permit of its
incision or removal from the bone, but the operative procedures in
these areas are comparatively few.
It is a remarkable fact that the brain, the great sensory organ of
the body, should itself be devoid of painful sensations. The entire
cerebral cortex of animals has been irritated and stimulated in many
ways without ever exciting any response indicative of pain, and we
have often removed considerable areas from the brain of a thoroughly
conscious patient without ever exciting any pain.
The knowledge of these facts permits us to undertake in suitable
cases many operations under local anesthesia upon the skull and
cortex of the brain which might otherwise seem impossible. In any
extensive operation upon the cranium it may prove desirable to use
circular constriction, with rubber tubing around the base of the
cranium; this, however, while often advisable with general anesthesia,
is superfluous with local methods, for here the use of adrenalin proves
an effective hemostatic, besides the constriction is often in the way,
and may prove annoying or painful to any but a patient under general
anesthesia unless the entire circumference of the cranium were anes-
thetized. Usually in severe traumatisms of the skull, such as extensive
or simple depressed fractures, the patients are often in a state of un-
consciousness from shock or brain injuries, which permit of painless
operating with very little local anesthesia, On the other hand, many
of these patients are in a condition of noisy delirium or turbulent rest-
lessness, which makes any operation under local anesthesia, even if
painless, inadvisable, and forces a resort to general anesthesia.
Omitting the above class of patients, there are a large range of
operations which permit of the use of local anesthesia. Simple abscesses
will require nothing further than a line of infiltration over the proposed
incision. -
Wounds.-For the cleansing and suture of incised, contused, and
lacerated, stab or superficial gunshot wounds, the most satisfactory
plan is, after a preliminary cleansing of the surrounding parts, to
create a wall of anesthesia around the wound, cleansing it later with a
more liberal cleansing of the entire area after the anesthetizing proc-
ess has been completed, as described in the chapter on Principles of
Technic.
Sebaceous cysts may be removed the same way, by a surrounding
wall of anesthesia and excising a triangular or oblong piece of the
skin with the tumor attached, approximating the gap with sutures; or
by infiltrating a line over the long axis of the cyst and splitting it
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 48I
open and pealing out the Sac. While this is a simple and thoroughly
effective method in non-infected sacs, in the event of infection it will
leave a Suppurating wound.
Benign tumors may be dealt with by the same method, also malig-
nant growths when Superficial and limited, as in epitheliomas, but if
extensive or deeply infiltrating had best be left to regional methods or
general anesthesia. In those cases of malignancy suitable for local
methods care should be exercised in making the injections to keep
well away from the growth, and surround it by a wall of anesthesia,
extending down to the cranium, so that this may be resected if the
growth is found attached.
As this same technic is applicable to all operations upon the scalp and
underlying bone, it is sufficient to state that it is suitable in depressed
fractures and for the evacuation of epidural or subdural hemor-
rhage, intracranial abscesses, and for the removal of necrotic areas of
the skull. Osteoplastic flaps of considerable extent are also just as
easily raised with local anesthesia and operations performed upon the
Cortex of the brain. Here local anesthesia possesses decided advantages
Over general anesthesia, particularly ether, which greatly congests
the entire cranial circulation, and is particularly troublesome when
Operating within the skull on account of the persistent oozing which
occurs from even the smallest vessels, and greatly adds to the danger
of postoperative hematoma. This entire picture is changed when
operating with local anesthesia; instead of the tremendous congestion
encountered, with ever-ready tendency to troublesome hemorrhage
difficult to control, with possible later oozing, the brain and its cir-
culation is found normal, and hemorrhage either does not occur, or is
easily controlled, with little or no tendency to postoperative oozing.
For this reason, if for no other, it is advised to consider local
anesthesia in all suitable intracranial operations, and when very
extensive to perform them by a two-stage operation, raising the Osteo-
plastic flap in the first stage under general anesthesia; this is then re-
turned to its place and lightly held with sutures, to be again raised
at a subsequent sitting, next day or later, the dura opened, and the
intradural procedure executed.
The advantage of this method is illustrated by the following re-
ports:
Mr. S., very stout, short man, weighing over 200 pounds, gave symptoms of tumor
near left motor area. Under general anesthesia a large osteoplastic flap was raised, ex-
posing the entire left motor area. The patient was very full blooded, and the entire
circulation of the head, face, and cerebrum became greatly congested; the cerebral and
31
482 . LOCAL ANESTHESIA
meningeal vessels were everywhere turgid with blood, and would certainly have given
trouble if the operation had been proceeded with; accordingly the wound was loosely
closed, after securing all bleeding-points in the external Soft parts, and the patient returned
to bed. The next day, after lightly injecting a cocain Solution into the incision, the sutures
were loosened and the flap raised; beyond this point no cocain was used. The operation
was everywhere painless, the patient conversing with us during the different steps of the
deeper procedure. A vast difference was now seen in the condition of the meningeal and
cerebral circulation, the vessels which previously had been turgid with blood were now
hardly to be seen, only a few small vessels of normal size encountered here and there.
The brain, which had previously been tense and bulging from the wound, now seemed
shrunken by comparison and lay well within the skull.
Two tumors were located back of the motor area and removed with a surrounding
margin of brain, resulting in a paresis of the right side of the body and tongue. The
patient was able to indicate during the entire procedure that he felt no pain. The wound
was then closed with a small drain, the patient making a satisfactory recovery, but died
about six months later from a recurrence of the malignant process. This case illustrates
clearly the advantages of a two-stage operation, or the entire procedure could have been
performed at one sitting with local anesthesia. The subsequent stage could, however,
have been done without any anesthesia, a preliminary hypodermic of an eighth or quarter
of morphin would have sufficed to relieve the fears and uneasiness of the patient; the
raising of the flap by the second day would not have caused any amount of pain, and, as
the deeper parts are without sensations, the second stage may possibly have been per-
formed this way.
This and many other experiences have strongly convinced me of
the advantages of using local anesthesia in Suitable cranial and intra-
cranial operations upon favorable patients, where it is known before-
hand just what is going to be done and the parts are all fairly acces-
sible. -
The following case illustrates a very satisfactory and fairly exten-
sive operation for the removal of necrotic bone and drainage of an epi-
dural abscess:
G. W. L. entered our service in the Delgardo Memorial, March, 1911, with a history
of a luetic infection nine years before. There were multiple gummas about the head, with
a sinus over the right ear which ran down to the bone, also a fluctuating mass 3 inches
above, which seemed to communicate with the sinus Operation under local anesthesia
(the patient in poor physical condition), a wall of anesthesia was created with solution No.
I, which ran from the ear below to the midline of the vertex above and measured about
3 inches across; this wall of anesthesia was carried well down to the pericranium. In a
few minutes anesthesia in the central area was complete. An incision was made down to
the bone connecting the swelling above with the sinus below; the swelling was found to
be broken-down gumma over a necrotic area in the skull which communicated with the
sinus below; the bone was removed between these two points, and revealed multiple areas
of necrosis on the inner table of the skull with numerous small sequestra; in all an irregular
area of the skull was removed which measured about 2 by 3 inches. The outer surface of
the dura, which was covered with foul granulations, was then cureted and the wound
packed and skin edges approximated. The patient was later given 606, and discharged
when the wound in the head had healed. He returned again the following October with
a similar condition near the site of the first operation, and was operated on in a similar way.
Both operations were entirely painless, and were performed as thoroughly as would have
been the case under a general anesthetic.
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 483
A very interesting case of a similar nature, illustrating the advan-
tages of a two-stage operation, or of performing the entire operation
under local anesthesia, is the following, reported by Drs. Thomas and
Cushing in the “Journal Amer. Med. Assoc.,” March 14, 1908: The
case, a rather dangerous one, had been operated on four times for a
tumor of the upper posterior Rolandic area. Much difficulty was
experienced from hemorrhage, due to the fulness of the vessels pro-
duced by the anesthetic and forced an abandonment of the operation,
the patient also doing badly under the anesthetic. One operative
intervention was made necessary for the removal of clots which re-
Sulted from the free Oozing from the congested vessels.
The fifth and last operation, at which time the cyst was removed,
was done under Cocain anesthesia, a preliminary hypodermic of
# gr. of morphin and rºw gr. of atropin given a short time before.
The following are extracts from Dr. Cushing's notes:
“Although the undertaking, as Dr. Thomas has said, was premed-
itated, etc., in Consequence of our previous unfortunate experience in
administering general narcosis to this patient we must confess to sur-
prise at its successful accomplishment. Contrary to all expectations,
the dura proved to be insensitive to such manipulations as were neces-
sary to freely open it. Only when it was put under tension or displace-
ment was any discomfort occasioned, otherwise it seemed to be abso-
lutely free from sensitivity. The conditions were similar in many
respects to those which are present in the visceral peritoneum, which,
according to Lennander, as well as our own observations, seem to
possess no sensory nerves, pain being occasioned only when the
viscera are so dislocated as to put the parietal serosa under abnormal
tension. -
“The danger of doing all the operation at one stage, owing to
hemorrhage, made greater by the congestion brought about by the an-
esthesia. If it should prove to be possible, however, to carry out the
second stage of an intracranial exploration without an anesthetic, this
would be a stronger argument for the two-stage procedure than the
mere avoidance of shock.
“It was truly remarkable in this patient’s case to find that the
extensive manipulations which were essential to the removal of the
tumor could be carried out while the patient was perfectly conscious,
and was chatting and taking a lively interest in the progress of the
operation.”
Numerous other cases could be mentioned in our own practice, as
well as in that of others, but the above will suffice to illustrate the
484 LOCAL ANESTHESIA
technic and possible extent of many cranial and intracranial opera-
tions. In Fig. 151 is outlined the operative area for subtemporal
decompression, the deep parts to be anesthetized as indicated by the
heavy dots. In this area it would, however, seem best to inject the
gasserian ganglion. In Fig. 152 is figured the operative area and points
of injection for operations upon the occipital region, as well as for ex-
posing the surface of the cerebellum.
To locate the supra-orbital, infra-orbital, and mental foramina,
Gray gives the following directions: “The supra-orbital foramen is
Fig. 151.-Points of injection and line of infiltration for craniotomy in temporal region.
(From Braun.)
situated at the junction of the internal and middle third of the supra-
orbital arch, between the internal and external angular processes.
If a straight line is drawn from this point to the lower border of the
inferior maxillary bone, so that it passes between the two bicuspid
teeth in both jaws, it will pass over the infra-orbital and mental for-
amina, the former being situated about 1 cm. (#inch) below the margin
of the orbit, the latter varying in position according to the age of the
individual. In the adult it is midway between the upper and lower
borders of the inferior maxillary bone, in the child it is nearer the lower

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 485
border, and in the edentulous jaw of old age it is close to the upper
margin” (Fig. 158).
The infra-orbital and mental nerves can be reached at the foramina
through the mouth or from without for paraneural injections. The
infra-orbital foramen is located by the tip of the finger, and is found
just above the root of the first bicuspid, about 4 to 1 cm. below the
rim of the orbital fossa (Fig. 156). With the finger held at this point,
the lip is raised and the needle entered high up slightly posterior to
Fig. 152.-Points for deep injections and line of infiltration for craniotomy over cerebellum.
(From Braun.)
the root of the canine tooth, and some little distance from the bone
nearer the labial than the alveolar attachment of the mucous mem-
brane, so that the needle in being advanced can be directed slightly
backward and upward (Fig. 157). The solution is injected as the
needle is advanced, until its point is felt just under the palpating
finger which locates the foramen; as the nerve hugs the bone in this
position, dividing into palpebral, nasal, and labial branches, the
injection must be made deep down in close contact with the bone;
about 2 drams of a 1 per cent. novocain-adrenalin solution is required,
-

486 | LOCAL ANESTHESIA
and in about ten minutes, if properly made on both sides, should
produce an area of anesthesia, as shown in Fig. 158. This injection
when well made diffuses back into the infra-orbital canal and reaches
the anterior superior dental nerves, which are given off but a short
distance back of the foramen and supply the canine and incisor teeth
(Figs. I44-160).
The infra-orbital foramen is situated about 1 cm. below the orbital
margin, about midway between the inner and outer angles, its axis
directed downward, forward, and inward, a continuation of this line
passing just over the middle incisor teeth.
The foramen is subjected to considerable variations, more par-
ticularly as to size, often being so small as to be difficult of entrance
with a needle when exposed by open dissection; its position and axis
also very slightly. However, the above will be found approximately
correct in the great majority of skulls.
If a point of anesthesia be established on the cheek over the recog-
nized position of this foramen, and the needle advanced from the
middle line below, keeping the syringe in contact with the midline of
the lip, and injecting as the needle is advanced, when after coming in
contact with the bone the canal can be sought for and often entered
when sufficiently patulous; when this cannot be done the injection
should be made deep down in close contact with the bone and just
below the known position of the foramen; I to 2 c.c. of a 2 per cent.
novocain-adrenalin Solution, when deposited at this point on both sides,
produces anesthesia after five to ten minutes. The anesthetic area
is shown in Fig. 159, as well as the underlying bone. -
Paraneural Injections at the Mental Foramen Made Through the
Mouth.--The mental foramen is situated at the base of the alveolar
process, between the first and second bicuspids. The lip is reflected,
and the needle advanced in this direction from the depth of the
mucous fold close down to the bone (Fig. 157), injecting as the needle
is advanced, depositing about # to I dram of I per cent. novocain-adre-
nalin solution over the foramen.
As the terminal fibers of the inferior dental nerve, both within the
bone at the symphysis as well as after emerging from the mental
foramen, freely intermingle with the branches of the opposite side, it is
necessary in operating in this region to inject both sides.
The free intermingling of the nerve, which takes place at the
symphysis, limits the extent of anesthesia, which takes place follow-
ing the injection of the inferior dental nerve of one side to about
the position of the first bicuspid of that side, but can be made
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 487
to extend well beyond the middle line by a mental injection of the
opposite side.
Paraneural injections at the mental foramen made from without
are done in the following manner: after locating the approximate
position of the foramen, which is directed upward and forward and
lies between the two bicuspids at a variable distance from the inferior
margin of the maxilla, depending upon the age of the individual, in in-
fancy being near its lower border; in adult life, about 1 cm. or slightly
more above; in edentulous old age, lying near the alveolar margin.
The needle is directed obliquely downward, backward, and inward
in the axis of the foramen, injecting as it is advanced; after reaching
the bone the foramen is searched for, and, if possible, entered; if not,
the injection made over its orifice.
If the injection can be made within the canal or time allowed,
ten to fifteen minutes, if the injection is made over the foramen, the
solution diffuses into the canal, and the resulting anesthesia, when in-
jecting on both sides, involves the lower lip and tissues of the chin,
the gum on its labial side, the teeth between the two foramina, and the
involved bone; the mucous membrane and gum on the inner side are
not anesthetized, as their nerve supply is from the lingual.
THE FACE
In superficial and minor operations upon the soft parts of the
face infiltration anesthesia of the area involved is usually the method
employed, and should be preferred for such operations as the removal
of moles, naevi, cysts, etc., and for the closure of Superficial wounds
or opening of abscesses.
For such lesions as epitheliomas, carbuncles, etc., some form of
regional anesthesia should be employed; this will depend upon the loca-
tion of the lesion; if on the nose and superficially situated, the field
is surrounded by a zone of anesthesia made well outside the limits of
the growth, passing the needle down, and injecting into the deep tissues
at one or more points, as shown in Fig. 153.
In Fig. I54 the method of anesthetizing the upper lip and nose is
shown. This plan will be found simple and effective for the removal of
naevi, cysts, and superficial operations. For such operations on the
lower lip a point of anesthesia is established over the midpoint of the
chin below, and the long needle with large syringe entered at this point;
with the finger in the mouth as a guide, it is advanced between the skin
and mucous membrane toward the angle of the mouth, infiltrating as
the needle is advanced with solution No. 2 (o.50 per cent. novocain and
488 LOCAL ANESTHESIA
adrenalin); the needle is now partially withdrawn and redirected in
the opposite direction and the procedure repeated (Fig. 155). This
Fig. 153.-Method of procedure for anesthetizing area of tumor on external nose. (Braun.)
embraces the intervening area between two walls of anesthesia, which
in a few minutes diffuse to skin and mucous membrane.
Superficial operations upon limited
areas of the lower jaw may be con-
veniently performed by surround-
ing the area by a wall of anesthesia
-
Fig. 154.—Outline of points of injection Fig. 155—Method of procedure for anes-
and line of infiltration for anesthetizing thetizing lower lip. (Braun.)
nose and upper lip. (Braun.)
in a similar manner, carrying the infiltration well down to the bone.
Such an operative area is outlined in Fig. 156, which shows the



THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 489
points for entering the long needle and advancing itin the deeperplanes.
In more extensive involvement of the bone this superficial infiltration
should be supplemented by blocking the inferior dental nerve at the
lingula, as referred to later. For operations upon the soft parts of
the face, advantage may be taken of the superficial position of the
infra-orbital and mental nerves as they emerge from their foramina
and block them at these points.
On the face all three branches of the fifth may enter the field
(Fig. 142). At the inner angle of the lower lid we have the infra-
trochlear branch of the nasal and, approaching the ala of the nose,
branches from the nasal; over the malar region of the temporomalar
nerves these form the first division of the fifth; in the infra-orbital
region, the second division, and over the side of the cheek the masseteric
and buccinator branches form the third division; below the line of
Fig. 156.-Points of injection and area of infiltration for minor operations on inferior max-
illa. (Braun.)
the mouth we have only the third division, but here the field is
also supplied by ascending branches from the superficial cervical
Iner VeS.
In operations in the infra-orbital region, extending down to and
involving the bone, as for malignant disease so frequently met with in
this region, the superior maxillary nerve may first be blocked by the
Matas intra-orbital or one of the lateral routes. The Peuckart medial
puncture of the orbit may now be used to control the nasal nerve and
its branches on the inner side of the lower lid and upper inner angle
of the face; if a wall of anesthesia is now carried down from the malar
prominence to below the line of the mouth, and made well down into
the subcutaneous tissues, it will effectively control the malar, masse-
teric, and buccinator nerves.
If the field is below the line of the mouth the inferior dental or
mental nerve may be blocked at their respective foramina, and the

490 LOCAL ANESTHESIA
cervical nerves controlled by a subcutaneous line of infiltration over
the lower border of the inferior maxilla.
For the areas of distribution of the branches of the fifth nerve
to the maxillae, teeth, gums, and hard palate see Figs. 160-163,
while the points of emergence of the peripheral branches upon the
Fig. 157-The supra-orbital foramen is located at the junction of the inner and middle
thirds of the supra-orbital margin; a line drawn from this point, passing between the two
bicuspids of the upper and lower jaw, should pass over the infra-orbital and mental
foramina. (After Sobótta and McMurrich.)
face and head is shown in Fig. 142. A study of this figure will prove
very useful for operations upon the peripheral soft parts. For the
innervation of the mucous passages and accessory sinuses a study of
Fig. 191 will be found very useful.
Operations upon the peripheral ends of the fifth nerve can be easily
done, as in resections for neuralgia. The foramina are first exposed

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE
491
No. 2 made into the canal,
1On
-
on of solut
ti
injec
incision and an i
by an
dvanced so as
ting as it is a
injec
advancing the needle very cautiously,
ſº??
%
∞∞∞× × ×%∞∞∞
ſaeae，
\\\\&&&&№&&3%£ €
∞∞∞Ķ3%º
■
∞
№№
№ae，
●№ae,~~~~）|-
§
S
§§?
--±
(After Fischer.)
by way of infra-orbital foramen.
1a.
Fig. 158.-Conductive anesthes
tal nerves at infra-
i
fter blocking both infra-orb
Fig. 159.-Resulting area of anesthesia a
)
(Braun
foramen.
will often
is way
in th
dram of solution used
1.
2
7
to progressively anesthetize the deeper parts of the nerve as they are
reached by the needle


492 LOCAL ANESTHESIA
flow back into the canal for some distance and anesthetize the nerve
far beyond the field of operation. After anesthetizing in this way, the
bony opening to the canal can be enlarged and the nerve reached fur-
ther back and excised; divulsion may also be practiced in a limited
way, but this method of anesthesia is not suited to severe traction
upon the nerve. -
*
§
º
‘W.
Post. Sup. dental nm.
Infra-orbital mn.
Zygomatic
process
Ant. sup.
dental nn.
Post. sup. dental mn.
Molars.
Incisors and Bicuspids Middle superior dental nm.
canines
Fig. 16o.—Areas of nerve supply of maxilla. Oblique shading: anterior superior dental
nerves (incisor and canine region). Horizontal shading: middle superior dental nerve
(bicuspid region); vertical shading: posterior superior dental nerves (molar region).
(After Fischer.)
While neuralgias in general, but especially facial neuralgia, were
among the first conditions for which cocain was used, its employment
in this way being almost as old as the discovery of cocain, neverthe-
less there have occurred apparent cures from its use alone; it would,
therefore, seem not inadvisable to bear it in mind, as the single injec-







THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 493
Nasopalatine notch
Anastomosis between anterior ~ *
palatine and nasopalatine
§rºw º:!...
§§ a ...:”
W \\
Hard palate.
Fig. I61.—Areas of nerve supply of palatine surface of maxilla, upper area, nasopalatine
nerve. Lower area: anterior palatine nerve (molar region). (After Fischer.)
º º º
ſº }: § *
}:\|||||| %||||||}|{{<};
* g /
Čš §llºš
... .º.º.º." ‘.j:”
f
ſ
|
t
%!
ſº
p
ſ
|
2.
* * *
&
Mental foramen” | fº
£2% &
Area partly supplied by buccinator n.
Fig. 162.-Area of nerve supply of anterior section of mandible. Dotted area: inferior
dental nerve. From the mental foramen emerges the mental nerve. The mucous mem-
brane in the molar region is partly supplied by sensory fibers of the buccinator nerve.
(After Fischer.)
tion of medicinal doses cannot possibly prove harmful. It must, how-
ever, further be remembered that its use for this purpose has nearly
always been in pure water, as well as in the present case reported, as




494 LOCAL ANESTHESIA
we know aquapuncture itself exerts this influence; it may, therefore,
in this and other cases not have been the cocain at all which accom-
plished the cure. The case in question is one by Fitzmiller, which
is said to have been very severe and in which all other remedies had
failed to afford relief (he does not state if aquapuncture had been
used): The patient a woman, aged thirty-two, had suffered almost
constantly with attacks often lasting a week in length; a o.17 per cent.
watery solution, containing a few drops of adrenalin, was used; of this
solution a half Pravaz Syringeful was injected at the points of emerg-
ence of the Supra-orbital, infra-Orbital, mental, and occipital nerves.
It is stated that immediate relief was afforded, the pain being as if
Lingual %.
W
$7||
jº # --Inºiſ, den-
º s
\
y
%
l/
yºff | %
.
º
Incisors and
canines Bicuspids Molars
*-*-
- *
by inferior
dental and
lingual nn.
&
&Z º
* : Mylohyoid n.
Area supplied by Lingual n.
inferior aental n.
Fig. 163.−Area of nerve supply of lingual section of mandible. Dotted area: in-
ferior dental nerve. The mylohyoid nerve branches off at inferior dental foramen.
(Fischer.)
“blown away,” leaving only a temporary feeling of numbness in the
areas of distribution of the nerves. During the next three weeks the
return of the pain required nine other injections, after which there was
no further return when last seen six months later. This case is merely
cited to call attention to its possible use in this way. *
Since the introduction of novocain this agent has been similarly
used, either in plain water or in Salt solution with adrenalin, and the
relief obtained from these injections has often been of prolonged dura-
tion. Its use for this purpose is not limited alone to facial neuralgia,
but seems to be equally beneficial when used elsewhere, as for Sciatica,
when infiltrated around this nerve, and for neuralgia of the spinal nerves
as in intercostal neuralgia; here the Solution had best be used as a





























THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 495
paraneural injection about the nerve-roots, thoroughly saturating
the nerve-roots for one or two nerves above and below the involved
area; in the hands of the author this method has often furnished pro-
longed relief.
In operations within the mouth which are not readily accessible,
as in lesions far back on the tongue, cheek wall, pillars of the pharynx,
etc., we often slit the cheek back to the ramus of the jaw, thus securing
greater room and freer access for work on these deeper parts. Such
incisions in the cheek, when properly closed, leave simply a linear scar.
Extirpation of the Tongue.—Such mutilating operations are
rarely indicated under local anesthesia. While possible in the hands
of a skilful operator, the physical effect is no doubt severe even upon
the most stoical. If the condition is one of malignancy, as is usually
the case, and well advanced, local methods of infiltration are contra-
indicated if they in any way encroach upon the diseased area.
Well-localized growths, when situated upon the anterior part of
the tongue, may be quite satisfactorily removed by creating a wall of
anesthesia—across the tongue, proximal to the lesion, and involving
its entire thickness; or, if the lesion is situated on the side near the tip,
a wall of infiltration anesthesia may be carried down the long axis of
the organ from its tip to beyond the lesion and joined at right angles
by a line of infiltration from the side; or, if limited to the anterior two-
thirds of the organ, the area of distribution of the lingual, this nerve
may be blocked on each side near the lingula.
To remove the entire organ the lingual and dental nerves should
be blocked on each side; this is preferable to blocking the inferior
maxillary higher up or to a ganglion injection, as the lingual receives
other nerve-fibers from its communications after it is given off from its
parent trunk.
As the base of the tongue receives fibers from the Superior laryngeal
and glossopharyngeal to its posterior one-third both of these nerves
must be dealt with. Block the superior laryngeal on both sides by
injections into the thyrohyoid membrane, as described in the chapter
on the Neck, and carry a line of subcutaneous infiltration through the
soft parts above the hyoid bone from side to side, to meet the ascend-
ing branches of the Superficial cervical.
The glossopharyngeal is anesthetized by blocking the Submucous
tissues below and in front of the tonsil toward the base of the tongue
on each side; then, with a finger in the floor of the mouth, the long
needle is passed in beneath the maxilla, and, guided by the finger in
the mouth, the root of the tongue on each side is infiltrated.
496 LOCAL ANESTHESIA
After a few minutes' delay anesthesia should be complete and the
inferior maxilla divided at its symphysis, or an incision made into the
mouth from beneath as preferred.
The author has never used local or regional methods for the re-
moval of tonsillar tumors, as, in my opinion, this region when the seat
of malignant disease, as most of these growths are, had best be operated
by general anesthesia; however, the method as outlined below is quoted
from Härtel:
“Operations for Tonsillar Tumors.-In the sensory innervation
of the tonsils the following nerves have a share—the nervus maxillaris
with the nervus palatinus medius, the nervus lingualis with the rami
isthmi faucium, the nervus glossopharyngeus with the ramus tonsil-
laris. While conduction anesthesia can easily be induced in the
nervus maxillaris and lingualis, this is impossible for the trunk of the
glossopharyngeus, because bone-points suitable for its location are
lacking. We must content ourselves with an infiltration of the peri-
pharyngeal connective tissue situated laterally to the tonsils, and
reach this region from a puncture point which is situated in the most
posterior point of the vestibulum oris laterally from the ligamentum
pterygomandibulare, which is there palpable; from here the tissue situ-
ated laterally behind the tonsils is infiltrated in a divergent direction.
Also from the lateral region of the
neck, tonsillar tumors, which usu-
ally are connected with collections
of glands in this region, can easily
be infiltrated accompanied by simul-
taneous palpation from within.”
The orbits are two quadrilateral
pyramidal cavities at the upper
and outer parts of the face, their
bases directed forward and outward,
Fig. 164—Schematic representa- their apices backward and inward;
tion of the orbital planes according to their axes, passing through the op-
Härtel. (Härtel.) - - -
- tic foramen, if continued backward,
would meet over the body of the sphenoid bone. The base of this
pyramid viewed from in front presents somewhat of a rectangular
appearance (Figs. 164 and 170), the plane of this rectangle sloping
downward, backward, and outward from the middle line of the face.
The roof of the orbit, triangular in shape, presents a perfectly
smooth concave surface, which slopes from the orbital margin first up-
ward, then downward, backward, and inward.
:
:
:

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 497
The Superior margin presents at its inner extremity a depression
for the pulley of the superior oblique, sometimes marked by a spicule
of bone. External to this point on the margin, at the juncture of the
internal and middle thirds, is the Supra-orbital notch or foramen.
On the lateral anterior surface, behind the orbital ridge, is the depres-
sion for the lacrimal gland.
The inner wall, after the lacrimal groove is passed, presents a
Smooth, irregular, slightly convex surface, directed almost directly
backward. This wall is extremely thin and paper-like in consistence,
forming the delicate bony external wall of the ethmoid and sphenoid
cells. -
At the angle of the junction of the roof and inner wall, in the suture
between the frontal and the ethmoid bones, are seen the anterior and
posterior ethmoidal foramina; the anterior, situated about the midpoint
of the depth of the orbital wall, transmits the anterior ethmoidal ves-
Sels and nasal nerve; the posterior foramen is placed about midway
between the anterior and the orbital foramen and transmits the pos-
terior ethmoidal vessels.
At the internal inferior angle is seen the lacrimal canal.
The floor presents an irregular smooth surface, sloping outward and
forward, slightly convex in its middle part, and concaved in front as it
approaches the orbital margin. It is crossed from before, backward,
and outward by the ethmoid maxillary suture. The bony surface of
the floor, like the inner wall, is extremely thin and forms the roof of
the antrum of Highmore.
The outer wall, sometimes deficient at the sphenomalar articula-
tion, presents a fairly smooth, slightly concave surface, which slopes
sharply backward toward the foramen lacerum anterius; on it are seen
the orifices of the malar canals.
The sphenomaxillary fissure extends about two-thirds of the dis-
tance along the angle of junction between the external wall and floor
of the orbit. It runs obliquely backward and inward to the spheno-
maxillary fossa. This fissure is widest in front, becoming narrower
and somewhat serpentine in direction behind.
It is formed above by the lower border of the orbital surface of the
great wing of the sphenoid, below and internally by the external border
of the orbital surface of the superior maxilla and a small part of the
palate bone.
At its internal extremity this fissure joins at right angles with the
pterygomaxillary fissure. This fissure forms a means of communica-
tion between four fossae—the orbital in front, sphenomaxillary behind
32
498 - LOCAL ANESTHESIA
and internally, the temporal and zygomatic externally and behind.
Through this fissure pass the superior maxillary nerve and its orbital
branch, the infra-orbital vessels, and ascending branches from the
sphenopalatine or Meckel's ganglion.
At the apex of the orbital fossa, below and external to the orbital
foramen, is seen the foramen lacerum anterius or sphenoidal fissure,
formed internally by the body of the sphenoid, above and internally
by the lesser wing of the sphenoid, below and externally by the greater
wing of the sphenoid.
Through this fissure pass the third, fourth, the three divisions of the
ophthalmic division of the fifth (lacrimal, frontal, and nasal), and sixth
nerves, some filaments from the cavernous plexus of the sympathetic,
the orbital branch of the middle meningeal artery, a recurrent branch
from the lacrimal artery to the dura, and the ophthalmic vein.
The relative position of these structures is seen in Fig. 165.
Lacrimal
g:
-
º. division of third
* Nasal
Inf. division of third
Frontal
Sixth
Ophthalmic vein
In making deep orbital injections for the purpose of blocking those
branches of the trigeminus which pass through this fossa on their way
to other parts, we should try to select such routes of puncture as lie
along smooth and regular bony surfaces, using these surfaces as a guide
in approaching the deeper parts, and always keeping the needle-point
in close contact with the bone; in this way, by keeping well toward
the peripheral limits of the orbit, we are in the zone outside of the eye
and its attached muscles. This idea of utilizing the orbit as a means of
approach to the intra- and retro-orbital nerve-trunks may appear
to the inexperienced as a hazardous procedure; this, however, is a
misconception, as the puncture under proper technic should be a per-
fectly innocent undertaking, except in the known dangerous region
of the orbit—in its axis or at its apex. In extensive operations
upon the eye, as in enucleation, these regions are intentionally


THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 499
invaded. (Figs. 166, 167 show the arrangement of the nerves
within the orbit.)
Fig. 166.-Ocular muscles viewed after removal of lateral wall of orbit: a, Eyeball;
b, optic nerve; c, c', eyelids; d, maxillary sinus; e, pterygoid plate; f, foramen rotundum;
g, roof of orbit; h, frontal sinus; i, supra-orbital nerve; k, septum orbitale; 1, levator pal-
pebrae superioris; 2, 3, superior and inferior recti; 4,4', portions of the cut external rectus;
5, internal rectus; 6, inferior oblique; 7, insertion of superior oblique; 8, annular ligament or
tendon of Zinn. (Testut.)
Nasal nerve
2-*-
Rectus superior
Annular *
Lachrymal nerve
Ciliary ganglion and nerves
Fig. 167.-Scheme of the ophthalmic nerve after Corning. (Braun.)
The recognized routes of orbital puncture are:
(1) Medial orbital route, first described by Peuckart for reaching
the nasal nerve (Figs. 168-176).







5oo LOCAL ANESTHESIA
Lateral orbital route of Braun for reaching the frontal and lacrimal
branches of the ophthalmic (Figs. 168, 169).
(3) Orbital route, through sphenomaxillary fissure to spheno-
maxillary fossa, to reach the second division of the fifth at the foramen
rotundum, the Matas route (Figs. 177-179).
(4) The retrobulbar methods of infiltration for bulbar operations
—the methods of Seigrist, Löwenstein, and others.
Fig. 168,-Base of skull with cranial nerves, from Arnold. Needles a and b same as Fig.
212, c to nasal nerve, d to frontal and lacrimal nerves. (Härtel.)
(5) In the method of Levy and Baudoin for reaching the ophthalmic
division of the first through the orbit, the needle is entered on the outer
wall of the orbit at the level of the inferior extremity of the external
angular process of the frontal bone and advanced backward and in-
ward beneath the lacrimal gland, hugging the bone to a depth of from
3% to 4 cm.
Discussing the orbit and its various points of puncture, Härtel has
presented this subject with much thoroughness and detail, often sur-

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5oI
passing in his clearness of presentation original routes advocated by
others. For this reason I quote him as follows:
“The puncture of the orbit from the front, as Braun rightly indi-
cates, may be undertaken only under continuous contact with the bone,
in order to avoid injury of the eye. But now appear certain dif-
ficulties, from the fact that the bony orbital margin bordering the
orbit in front has a shorter diameter than the cavity of the orbit situ-
ated behind it, and also in its shape it in no way conforms to this. On
this account there exist in the walls of the orbit concavities which
ſ ºr C
Fig. 169-Horizontal section of skull in upper horizontal plane seen from above.
Needle c is at the ethmoidal foramina (nasal nerve); needle d at the superior orbital
fissure (frontal and lacrimal nerves); I and 2, anterior and posterior ethmoidal foramina;
3, superior orbital fissure; 4, optic foramen. (Härtel.)
thwart “bone-feeling.” Only in certain places do plane surfaces
variable in the individual present themselves to us, which we can
utilize for routes for injection. The walls of the orbit are in a high
degree dependent on the pneumatization of the adjacent facial cavi-
ties (ethmoid cavity, frontal sinus, sphenoid sinus, antrum of High-
more). This is the cause of the extraordinary variability of the orbital
walls. On account of these relationships ‘bone-feeling' as the single
guide of our needle is often problematic, particularly as the paper-thin
walls often do not offer satisfactory resistance. We need, therefore,

502 LOCAL ANESTHESIA
here also the adherence to certain instruction for direction as well as
for definite depth.
“The deepest concavities of the orbit lie above behind the margo
supraorbitalis and outward under it, while the medial wall (lamina
papyracea), the lateral wall (orbital surface of the malar bone and
great wing of the sphenoid bone), and the medial part of the inferior
wall (orbital surface of the upper jaw) usually afford plane relation-
ships. We obtain, therefore, a medial, a lateral, and an inferior plane
surface of the orbit. From the medial plane surface we reach the for-
7 ": - o to II 12 13 I4
Fig. 17o-Orbit from in front (photo from a skull with wide fissures): 1, Ant. eth-
moid. for.; 2, frontal notch; 3, supra-orbital notch; 4, post. ethmoid. for.; 5, for. opticum;
6, sup. orbital fissure; 7, lacrimal fossa; 8, malar-maxillaris suture; 9, infra-orbital
foramen; Io, infra-orbital canal; II, foramen rotundum; 12, planum pterygoideum; 13,
inf. orbital fissure; 14, malar-frontal suture. (Härtel.)
amina ethmoidalia, from the lateral plane surface the fissura orbitalis
superior with the entrance of the nervus ophthalmicus, from the inferior
plane surface the nervus maxillaris and the foramen rotundum.
“Concerning the quality of the plane surfaces, Table II, Nos. 15,
16, and 17, gives explanation. According to that, the medial plane
surface offers the most favorable relationships (80 per cent completely
plane way; in the other 20 per cent. a very slight concavity or convexity
of the planum, not interfering with puncture). Less favorable rela-
tions are found in the lateral and the inferior plane surfaces.

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5O3
“As the concavities of the orbit, as we have seen, lie in its anterior
part close behind the orbital margin, in every case information con-
Cerning the quality of the plane surfaces is possible by palpation.
Therefore, before the puncture we can seek out the most favorable
place by examination, and, by shoving the bulbus to one side, we can
carry the needle into the depth, even if the relations are not entirely
plane, without injuring the bulb.
“If we now observe the orbital margin (Fig. 170) in the choice of
our puncture point, its configuration in the individual is so varied that
even to-day the anatomists are not united concerning the designation
of the margins and corners. For us it is important to note definite
points palpable through the skin. They are these: the sutura malar-
maxillaris on the inferior margin, the sutura malar frontalis above
laterally, the lacrimal fossa, as well as the usually palpable incisurae
Supra-orbitalis and frontalis. We compare the orbital margin to an
obliquely placed rectangle (c, e, b, f, Fig. 164), whose corners are
formed—laterally above (b), by the sutura malar maxillaris, toward
the median line; above (e) by the incisura frontalis, toward the median
line below (c) by the lacrimal fossa, laterally below (f) by the rounded
orbital margin. In most cases three of these corners are palpable,
Now this rectangle lies diagonally, so that the horizontal line drawn
through the superior outer angle (b) (sutura malar maxillaris) meets
the opposite short side in the middle (a), and the horizontal line,
drawn from the inner inferior angle (c) (middle of the lacrimal fossa),
the middle of the outer short side (d). We designate these two lines
ab and cd as superior and inferior horizontal lines of the orbit, and we
shall find that the horizontal planes passing through these lines offer
the following important relations to direction for the puncture of the
Orbit:
“If we observe the orbit exactly from the front, so that our direc-
tion of vision corresponds to the central axis of the orbit, then we per-
ceive as the middle point (Fig. 171) of the orbital infundibulum the
inferior wide part of the fissura superioris. It lies exactly between the
two horizontals of the orbit. In the upper horizontal plane lie, from
the outside toward the median line, the upper part of the fissura orbit-
alis Superioris, the foramen opticum, the foramina ethmoidalia, pos-
terior and anterior. In the lower horizontal plane lies the foramen
rotundum. If we keep our needle in the horizontal planes, then we
assuredly avoid the puncture of the broad inferior end of the fissura
superioris, which contains the nerves of the muscles of the eye and
large veins. On puncture in the upper plane we encounter laterally the
504 LOCAL ANESTHESIA
place of entrance into the orbit of the nervi frontalis and lacrimalis,
medially the place of entrance of the nasal nerve. In this connection
precaution is to be observed only in so far as danger exists of injury of
the nervus opticus by going too deep. In the lower horizontal plane
we encounter the nervus maxillaris and its orbital branch, the temporo-
malar.
“Fig. 172 shows the orbit with bulb, conjunctival sac, palpebral
fissure (after Merkel), as well as the horizontals ab and cd specified by
us, and the puncture-points for medial (1), lateral (2), and inferior (3)
orbital puncture.
Fig. 171.-Orbit from in front, same specimen as Fig. 17o with the horizontal planes out-
lined. (Härtel.)
“If we ask ourselves how the palpebral fissure is related to our
puncture points, then we must remember this, that only the inner
angle of the palpebral fissure is a fixed point, while the external angle,
when the eye is opened, moves upward several millimeters. The
inner angle of the palpebral fissure lies in the region of the lacrimal
fossa, and the palpebral fissure occurs varying in its height, in any
case always in the region situated between the two horizontal planes
of the orbit. With the eye moderately opened the superior and in-
ferior palpebral margins should correspond to the two horizontal planes.
Therefore, the puncture point for the medial puncture as well as the
puncture point for the lateral puncture lies above the palpebral fissure,
as is evident from Fig. 172.

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 505
“Further, we must bear in mind that the central axes of the two
orbital cavities converge posteriorly; consequently, the lateral orbital
Wall runs diagonally from in front backward toward the median line
at an angle that deviates about 45° from the sagittal. The projections
of the straight lines drawn along the outer orbital walls meet in the
region of the dorsum Sellae at right angles. The medial orbital walls,
On the other hand, run approximately sagittally and diverge but little
from behind forward.
“If we observe the rules here mentioned, then on making the orbital
punctures we can assuredly avoid an injury of the bulb and of the nervus
§
º § N
NY.
Q sº §
§ §ºA
§§§
& W
º . § º º: ſº
3.
%& ſº
lº
j,
Fig. 172.-Orbit and eye, showing outlines or orbital margin. Heavy circle shows
limits of the bulb; dotted circle, limits of conjunctival sac. a-b, Upper horizontal plane;
c—d, lower horizontal plane; I, median point of puncture for injecting nasal nerve; 2,
point of puncture for injecting frontal and lacrimal nerves; 3, point of puncture for orbital
injection of foramen rotundum. (After Merkel.)
opticus. In practice we displace the bulb with the finger from the
point of entrance, and carry the needle into the depth between the
orbital wall and the finger-tip that protects the bulb. By this means
we keep the needle in the region of the horizontal planes mentioned,
and guard against the point of the needle entering the region bounded
by both planes and from getting accidentally into the point of the
orbital infundibulum. On lateral orbital puncture the axis of the
needle is at 45° from the Sagittal direction, on medial and inferior punc-
ture approximately Sagittal.













506 LOCAL ANESTHESIA
“If the injury of the bulb and nervus opticus is thus technically
avoidable, this, however, is not true with equal certainty of the
vessels of the orbit. These are related in detail as follows: On medial
orbital puncture we come in contact with the terminal branches
of the ophthalmic artery, while the trunk of the artery itself lies
within the muscular infundibulum of the orbit and is avoided by
keeping in contact with the bone. On lateral puncture we may en-
counter the lacrimal artery; on puncture of the foramen rotundum
the anterior infra-orbitalis and the communication of the ophthalmic
vein with the deep veins of the region of the cheek. One may say
that, with cautious work and by constant contact with the bone,
the appearance of hematoma during the orbital punctures is very rare.
However, it is not to be excluded, and while these puncture-hematoma
are accompanied by no danger, yet they cause temporary exophthalmus
and leave behind suffusions of the lids and of the conjunctiva which
are visible for several days. For this reason we should use nerve punc-
tures in the orbit only for the anesthesia of major procedures.
“(1) Medial Orbital Puncture (Peuckart Route). Anesthesia of the
Nervi Ethmoidales (Figs. I68, 169c, 176).--Where the upper hori-
zontal plane touches the wall of the orbital cavity, the foramina eth-
moidalia and the foramen opticum lie in one line. In front the same
plane meets the root of the nose. The puncture-point, therefore, lies
on the inner orbital margin at the height of the root of the nose. The
needle is entered in an exactly horizontal and approximately sagittal
direction in constant contact with the bone. The distance of the
foramen ethmoidale anterius from the inner margin of the orbit amounts,
according to Table II, No. 19, to from 15 to 22; on the average, 18.5
mm.; therefore, for the anesthesia of the nervus ethmoidalis anterius
(nasal nerve) we will carry the cannula in to the depth of about
2 cm. The nervus ethmoidalis anterius (nasal nerve) is distributed
to the Superior and anterior parts of the nasal mucous membrane
(compare Table I) and to the tip of the nose. In order to strike
the nervus ethmoidalis posterior, which is distributed to the ethmoidal
cells and the sphenoidal cavity, we must carry the needle to greater
depth. The foramen ethmoidale posterius lies at a distance from the
inner margin of the orbital cavity (see Table II, No. 20) of from 29 to
42; on the average, 34 mm. This is not so typically placed and con-
stant as the foramen ethmoidale anterius; it is often met with double.
Concerning its relation to the foramen opticum which, as we saw, is
situated in the same plane, the following is true: In a series of cases the
medial orbital wall curves forward somewhat in consequence of pneu-
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 507
matization of the Small wing of the sphenoid bone, so that behind the
foramen ethmoidale posterius the cannula strikes against bony resist-
ance. But this is the case only in half of the skulls (Table II, No. 18).
The distance of the anterior margin of the foramen opticum from the
inner margin of the orbital cavity amounts to 37 to 47; on the average,
40.8 mm.; in I case it amounted only to 33 mm. (compare Table
II, No. 21). If we compare with this the values found for the depth of
the foramen ethmoidale posterius, then we see that on anesthesia of
the nervus ethmoidalis posterius we come into dangerous proximity
to the optic nerve. Therefore, we do well to carry the inner orbital
puncture not deeper than 3 cm., and to forego the deeper penetration
to the diffusion of the injected solution.
“(2) Lateral Orbital Puncture (Braun Route). Anesthesia of the
Nervi Frontalis and Lacrimalis (Figs. 168, 169, 176).-In the upper
horizontal plane of the orbit is the lateral end of the fissura orbitalis
Superior with the passageway of the frontal and lacrimal nerves. We
reach this point by the lateral orbital puncture after Braun, and par-
ticularly by a puncture-point which is situated at the upper lateral
corner of the orbital margin (sutura malar-frontalis), or, with poor
development of the lateral plane surface, somewhat deeper on the outer
orbital margin. If we proceed from here with the needle in horizontal
position, and deviating from the Sagittal direction about 45 degrees
toward the median line in constant contact with the bone into the depth
of the orbit, we strike the outer end of the superior fissure, and on the
further side of this in most cases encounter bone-resistance on the
superior roof of the orbit (small wing of the sphenoid bone). Only
with a wide superior fissure does the danger exist that the cannula
without resistance may penetrate into the cranial cavity. According
to Table II, No. 22, we find this relationship in 14 per cent. of the
skulls. The distance of the outer end of the superior fissure from the
lateral orbital margin is very variable; according to Table II, No. 23,
it amounts to from 27 to 40 mm.; on the average, 33.5 mm. This
relationship makes the lateral puncture of the Superior orbital fissure
somewhat uncertain, so that I do not believe that it will ever come into
consideration for the injection in cases of neuralgia. For local anes-
thesia I advise penetration to a maximum depth of about 3 cm.
“(4). Aacial Puncture of the Foramen Rotundum. Orbital Way to
the Second Branch of the Trigeminus (the Matas Route, Author) (Figs.
177, 178).-If we observe the anterior surface of the sphenoid bone,
which is turned toward the orbit (Fig. 173), then we discover the follow-
ing details: the foramen opticum, the superior fissure, and underneath
508 LOCAL ANESTHESIA
this a surface shaped like an irregular triangle, the anterior wall of the
process pterygoideus. This surface, which we wish to name ‘planum
pterygoideum,” is limited above, opposite the orbital surface of the
large wing of the sphenoid bone, by a clearly perceptible sulcus.
This sulcus forms the path by which the nervus maxillaris, leaving the
foramen rotundum, reaches the sulcus infra-orbitalis. Likewise, on
the back of the upper jaw, a groove lies opposite this sulcus, so that,
by the closing together of these two half-grooves, a kind of canal is
formed. At the back end of this canal, in the body of the sphenoid
I 2
7
Fig. 173–Left half of sphenoid bone seen from in front: I, Lesser wing; 2, superior
orbital fissure; 3, orbital surface of greater wing; 4, foramen rotundum; 5, groove for sec-
ond division of fifth nerve; 6, sharp bony edge; 7, anterior surface of pterygoid process; 8,
sphenoid cells; 9, vidian canal. (Härtel.)
bone, lies the foramen rotundum, at its anterior end, in the upper
jaw, the canal infra-orbitalis. The lower outer margin of the planum
pterygoideum forms a sharp bone-corner, the limiting ridge; beyond
this lies the fossa infratemporalis.
“If on the skull we carry a cannula from the lateral part of the
inferior orbital margin sagittally into the depth, then we arrive
through the fissura inferior at the canal just mentioned, between the
sphenoid bone and the upper jaw, at the end of which canal lies the
foramen rotundum. Previously, however, the needle encounters bone-
resistance on the planum pterygoideum of the sphenoid bone. If we



THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5og
now feel with the point of the needle along this resistance upward and
medially, then we must reach the foramen rotundum. The supposi-
tion, by all means, is that the inferior fissure is wide enough and is not
too tortuous. On this account, the way described is, according to our
examinations (Table II, No. 24), accessible only in 89 per cent of the
skulls; in the rest of the cases it is obstructed by the inferior fissure.
“The distance of the foramen rotundum from the inferior orbital
margin amounts (Table II, No. 25) to from 39 to 51 mm.; on the aver-
age, 45.4 mm. For the direction of the cannula the following is of
value: the foramen rotundum never lies higher than the inferior hori-
zontal plane of the orbit. The cannula, when carried into the foramen
rotundum on lateral observation, points to the superior margin of the
auricle (Fig. 174); on observation from in front, it points with much
Fig. 174. Fig. 175.
Figs. 174 and 175—Front and lateral views of needle in position in the orbital injec-
tion of foramen rotundum. Front view shows long axis of needle reaching upper inner
angle of the orbit; on lateral view it is seen to reach upper margin of ear. (From a ca-
daveric specimen.) (Härtel.)
shorter axis to the inner superior angle of the orbit, the incisura fron-
talis (Fig. 175).
“For the orbital puncture of the foramen rotundum the following
is important: The foramen is very narrow, and is completely filled
by the nervus maxillaris, hence, on introducing the cannula we have to
reckon with the resistance of a tolerably firm mass of tissue, so that the
injection demands a certain pressure. If this resistance is lacking
and the needle glides easily into the depth, then we must suppose that
we have gone beyond the foramen rotundum into the superior orbital
fissure. In the living subject the most important guide for our punc-
ture is the subjective statement of the patient regarding radiating
pain in the region of the second branch of the trigeminus.” (See Table

I.)
5Io LOCAL ANESTHESIA
The axial injection of the foramen rotundum, the Matas route
through the orbit and sphenomaxillary fissure, has been erroneously
credited by Braun, Härtel, and others to Payr; this, however, is an
error, as the conception of this method of approach and its first ap-
plication undoubtedly belong to Prof. Matas, who first used it in 1898,
and it was published by him in his report on “Local and Regional
Anesthesia,” etc., to the Louisiana State Med. Soc., April, 190o.
Quotations from this report are given later on.
This successful application stimulated other efforts in this direc-
tion, and much of the work which appeared in the few years following
along these lines undoubtedly received the idea and stimulus from this
procedure.
Anterior and posterior ethmoidal foramina
Fig. 176.-Median and lateral orbital injections. (Braun.)
In studying the orbit, with a view of the application of the various
methods, we see that the foramen rotundum is concealed from view
just below the floor of the orbit, and that if this plane were used as a
means of reaching it the needle, if directed toward the apex of the
orbit medially along the floor, would pass into the superior orbital
fissure, and meeting no bony resistance here may, if advanced too far,
pass backward into the cranial cavity. This route, however, is dis-
cussed by Härtel (Fig. 179).
This would seem a more dangerous route, and not likely to lead to
the foramen rotundum, but above it.
The original route, as advocated by Prof. Matas, traverses the orbit
for but a short distance, as the needle soon passes out of this cavity into
the sphenomaxillary fissure (Figs. 177, 178).
If the sphenomaxillary fissures are observed, they will be seen to
run at right angles to each other and about on a horizontal plane;

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5II
their axes if continued back would meet over the body of the sphenoid
bone, and if projected forward would emerge at the inferior external
angle of the orbit; also, that the axis of this fissure, if raised to a slightly
Fig. 177.-Matas' intra-orbital route to foramen rotundum. (Braun.)
elevated plane, would pass through the orbital foramen or superior
orbital fissure at the apex of the orbit.
The axis of the foramen rotundum, if viewed from within the skull,
passes downward, forward, and outward, and passes through the
Fig. 178–Needle in position in Matas' intra-orbital injection within foramen rotundum.
(Braun.)
sphenomaxillary fossa, and for a short distance through the spheno-
maxillary fissure, and emerge upon the rim of the orbit just internal


512 LOCAL ANESTHESIA
to its inferior external angle, at a distance of from 4 to 5 cm., varying
somewhat in different skulls.
It will be seen from the above that undoubtedly the safest method,
as well as the surest of approach to the foramen rotundum is by the
Matas route, for if a plane above this route is taken the needle may
pass on without resistance into the cranial cavity, but if the route is
followed by passing through the sphenomaxillary fissure that the
needle-point impinges upon the body of the sphenoid bone, on the
I 2
*
- ** -
Fig. 179-Horizontal section of left half of skull in lower horizontal orbital plane,
seen from above, with needle in foramen rotundum: I, Infra-orbital sulcus; 2, zygomatico-
maxillary suture; 2, infra-orbital fissure; 4, foramen rotundum; 5, foramen ovale.
(Härtel.)
posterior surface of the sphenomaxillary fossa; and if unable to enter
the foramen rotundum through insufficient play of the needle, due to
the narrowing of the sphenomaxillary fissure, is at least in immediate
contact with the nerve; but, if after reaching the posterior wall of the
fossa the foramen is felt for, by gentle manipulation immediately around
the axis of the needle, the foramen may often be entered, when the
needle may be advanced a few millimeters further and the injection
made.

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5I3
The proof of contact of the needle with the nerve is recognized
by the radiating pains along the branches of this nerve, felt on the
cheek, in the upper teeth, and in the nose.
Having reached with certaintly the position of the nerve, 2 c.c. of
a 2 per cent. novocain-adrenalin solution are injected, or if the point
of the needle be less accurately placed and injection of a slightly larger
quantity of a weaker Solution (I to 2 drams of a 1 per cent.) will flood
the Sphenomaxillary fossa and reach the nerve and all its branches.
According to the studies of Härtel the foramen rotundum is accessible
in about 89 per cent. of skulls.
The following case illustrates the early use of this method by Prof.
Matas, and is his first report of the use of this route (“Local and Re-
gional Anesthesia,” etc., Prac. Louisiana State Med. Soc., 1900):
“A white man, laborer, aged forty-eight, addicted strongly to alcohol for years and
suffering with advanced arteriosclerosis, was admitted to Ward 7, Charity Hospital
(April 29, 1899), for treatment of a recurrent epithelioma of the palate, involving the
anterior alveolar arch and both upper maxillary processes. The neoplastic infiltration
extended to the right half of the palate and along the entire incisor region to the first right
bicuspid; the anterior half of the hard palate also presented a large ovoid swelling
caused by malignant periosteal invasion. I decided that I would try to remove the entire
hard palate, including both palatine processes of the upper maxillae, the floor of the an-
trum, and the septal cartilage of the nose. A hypodermic of morphin, ; gr., was given
twenty minutes before the operation. In order to anesthetize the maxillaries and the
palate, the sphenopalatine fossae were filled with a No. 1 Schleich solution, introduced by
a long needle through the sphenomaxillary fissures. The needle was directed as closely
as possible through the fissure in the right orbit toward the infra-orbital nerve as it enters
the infra-orbital canal. In this way it was expected that not only the entire superior
maxillary division of the trigeminus could be anesthetized, but that Meckel's ganglion
with its palatine branches would be ‘blocked' by the anesthetic. In a few minutes we
tested the sensibility of the cheeks, lips, and alae of nose, and were gratified to find the
entire cutaneous distribution of the infra-orbital had been completely anesthetized on
the corresponding (right) side. Encouraged by this result, the left sphenopalatine fossa
and infra-orbital nerve were treated in the same manner with identical results. Fully
5o minims of Schleich's No. 1 solution, reinforced by 25 minims of I per cent. cocain, were
injected into each sphenopalatine fossa. The nasal septum, which is supplied by the
nasopalatine and the nasal branch of the ophthalmic, was controlled by a separate infiltra-
tion, a long needle being introduced through the frenulum of the upper lip into the root
of the columna and septal cartilage of the nose. The anesthesia of the posterior palatine
nerves was also reinforced by direct infiltration in the palate. When the last injection
had been completed the patient said that his palate and face felt entirely ‘numb,” and
gave the impression of a ‘dead block of flesh' wedged in his head. The anesthesia of the
jaws was then tested by extracting a perfectly sound right canine which was firmly
implanted in its socket. The patient was surprised when he saw his tooth, saying he had
not felt the least pain in its extraction. The upper lip was then divided in the median
line and detached from the nose by two lateral incisions, which were carried along the
lower border of the columna nasi and to the nasolabial groove. The lips were then dis-
sected away from the gums and jaws as far back as the tuberosities of the maxillae. The
two halves of the upper lip were then reflected outward, and then held out of the way with
33
5I4 LOCAL ANESTHESIA
loops of strong silk which acted as retractors. A very sharp McEwen's chisel was then
driven by hand into the body of the right maxilla on a level with the floor of the nose.
With a few sharp strokes of the mallet the palatine process, including the tuberosity,
was divided, and the antrum was exposed; the same process was repeated on the other
side, and the separation of the septum nasi from the jaws completed the line of osseous
section. In this manner the lower half of both upper jaws and the entire hard palate with
the attached growth were mobilized and displaced downward en bloc, the connections with
the soft palate being severed with a long pair of strong curved scissors. After the removal
of the palate, both antral cavities and nasal fossae were widely exposed. The bleeding was
very profuse in the last stage of the operation when the palate was being detached, the pal-
atine arteries spurting vigorously. A large tampon of iodoform gauze, impregnated with
compound tincture of benzoin, was immediately packed into the palatine region and
promptly arrested the hemorrhage. The lining mucosa of the right antrum was subse-
quently removed in its entirety. During the intra-oral part of the operation the patient’s
head was kept low, in Rose's position. Throughout the whole procedure, which lasted
over forty minutes, the patient gave us great assistance by Spitting out clots and altering
the position of the head as we directed. He said that while the chisel was being used he
felt the jar of the instrument, the detachment of the vomer gave him some pain, but what
gave him more alarm than anything else was the sight of the blood that he spat out.”
“In this case the preliminary injection of morphin was of decided
assistance in diminishing psychic anxiety. Fully 180 min. of Schleich's
No. 1 (# of I per cent.) Solution and 6o min. of a I per cent. So-
lution were used in the operation. After the removal of the palate
the lip was still completely anesthetized, and the facial (cutaneous)
and intra-oral (mucous) sutures were introduced without pain. The
patient was very much exhausted by the ordeal he had undergone, but,
after taking a good drink of whisky and a hypodermic of Strychnin,
he sat up, and said that, apart from the jarring of the chisel and the
excitement of the operation, he had suffered comparatively little pain.
The pulse was IIo and there was little shock.”
The use of any but straight needles in making these deep orbital
punctures is to be advised against, as cautioned by Braun; however,
these are very useful for retrobulbar infiltration according to the
Löwenstein technic, but should not be used for other injections.
Such injections, made according to the proper technic, should not
effect the innervation of the bulb, optic nerve, ciliary nerve, or its
ganglion; to reach these the injection should be made retrobulbar.
The following excellent description of the position of the inferior
dental foramen and the method of making a paraneural injection here
has been taken from Fischer:
This, one of the most accessible of the cranial nerves, is not as
accurately reached as one might Suppose, and in the hands of even
skilful surgeons, who resort to this procedure but occasionally, many
failures may occur. It is far easier to make an accurate injection in
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5I5
contact with the parent trunk (third division of the fifth) at the base
of the skull than to accurately inject this nerve here, both for purposes
of anesthetization as well as alcoholization in cases of neuralgia.
In the one case the end may be obtained by using a large amount
of anesthetic fluid, but this as it diffuses in all directions produces
a very unpleasant sense of paralysis of the throat, which is quite terri- -
fying to Some patients, particularly if it occurs during the progress
of an operation.
An alcohol injection, if too liberally made at this point, may result
in a more or less prolonged trismus through the action of the alco-
hol upon the masticatory muscles. w
Sigmoid notch
\ Pterygoid depression
\ \ Condyloid process
\ \
Inferior dental foramen --_
Internal oblique line *~
.** s }l t
H gº •/º
§ *: tº º ſº
º g * , f' ºf A g ‘.. *
sº ... //zº º Ž : ".
Rºº? & • . *.* • * . º ‘. & ſe
Sºx, º/// º,”, , Ø
ſº º/* %2% 3% .2%.”
º ºzz’’., . z/ZººZºº?"
%22. % . . .'; T.,’ 4% tº
%. % º % . % ... ... % 3& ſº º *Angle
º | {
} Submaxil. Mylohoid
A lary fossa groove
| *
Internal genital Mylohyoid
tubercles ridge
Fig. 180.-Side view of inner surface of right half of mandible. The long arrow indi-
cates the direction in which the needle should be pushed forward over the lingula. The
dotted circle indicates the area of injection. (Fischer.)
The inferior dental or oblique mandibular foramen in the internal
surface of the ascending ramus permits the passage of the inferior
dental nerve, which, with the inferior dental artery, passes forward
in the dental canal of the mandible as far as the mental foramen, where
it divides into two terminal branches, incisor and mental. For the
technic of injection in the oblique foramen the relationship of the body
of the jaw to the ascending ramus and that of the muscles to the
foramen is of vital importance.
In adults the ascending ramus begins a little behind the third
molar, sometimes in an abruptly ascending surface. At its basis,
which must be regarded as resting upon the alveolar process, the as-































516 LOCAL ANESTHESIA
cending ramus, in front view, shows an outer buccal anterior ridge,
representing the last ascending portion of the external oblique line.
(See Figs. 180–182.) About o.5 cm. inward and backward of this line
runs a ridge bordering the lingual surface, the internal oblique line,
which gradually loses itself in the posterior section of the coronoid
process. Between these two lines in the bony surface is situated a more
Condyloid process
W
§§ -
§§§ A
ºf ſ º
". * 7 A.
* , 4 \ z:
ſ- Coronoid process
foramen ---H. |7}
£ / __Internal oblique
7.7/. line
º | External oblique
|| || || --- line
Inferior dental º i
Lingula——
Retronuclear —
fossa
§§) tº _Internal oblique
Mylohyoid ridge--ſº
ſ§;
i
Fig. 181.-Relationship of the ascending ramus to the body of the jaw. The arrow
indicates the direction in which the Syringe should be advanced to the inferior dental fora-
men. (After Fischer.)
or less pronounced deep groove, which we might call the retromolar
fossa (Fig. 181). Above this fossa the mucosa is slightly depressed, in
what might be called the retromolar triangle.
About the middle of the internal surface portion of the ascending
ramus the large inferior dental or mandibular foramen is situated,
extending downward and forward, at the same time marking the
termination of the mylohyoid groove which ascends from below ante-












THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5I?
riorly to above posteriorly. The orifice of the foramen itself is more
or less protected anteriorly by a spicule of bone varying in size, the
mandibular lingual (Figs. 180–182).
Lingula
/
Coronoid--_
process
~-Condyloid process
/
2– 2%Z_Inferior dental
...!
foramen
Z--.Angle
ſ
Coronoid. – 1– ſº
process \ %2 º,
Ž/2.3
j / % —/ -- Condyloid process
ea
&º
Z__Inferior dental
B UK *2 y 7TT foramen
4
//
º
z
/2
% % sº — `Angle
Z!
3 º 2 Sigmoid notch
| | |
, / ; )
Coronoid–– - | | // %
process h | A Condyloid
|| || % % ', process
e iſ ſ %%
Internal oblique ... .9% ,
line % z %º %
*~ 44 - Lingula
//º º
a * | _Inferior dental
.2× process
T/
/
/ T. Angle
/
Mylohyoid ridge . Submaxillary Mylohyoid
fossa groove
Fig. 182.-Variations of the inferior dental foramen at different ages: A, Mandible
of a child, aged seven years (the needle should be inclined slightly downward); B, mandible
of a youth, aged eighteen years; C, mandible of a male adult, aged thirty years. The
arrows indicate the direction of the needle. (After Fischer.)
This lingula may be developed as a pointed plate of bone, or as a
tongue-like cover, or only as a thickened process on the anterior margin.




518 LOCAL ANESTHESIA
Sometimes the lingula"is connected with the lower free margin of the
orifice of the foramen by a small spicule or bridge.
*Cºttº, * , a //
Fig. 183.—Front view of position of syringe in mandibular anesthesia: I, Internal
oblique line; 2, external oblique line; 3, insertion of needle about I cm. above masticating
surface of molars. (After Fischer.)
The foramen itself, in adults, is always situated above the alveolar
ridge and in a horizontal plane, about 1.5 cm. from the anterior ridge
of the jaw (the external oblique line) (Figs. 182-184).
SWa
ſº º)==
|W
#
g
º
#EE::::::::: ; sº-F5
gº-3 º::==ºº-
N | º
ſº
sº //// \
\ wº - | º
'il I
sº
(ſ “I
ºl. ! h!ht | t!! *
{{ }
f = 2* %
|'. / ſº
lſº
%
Fig. 184.—Position of needle in mandibular anesthesia: I, External oblique line; 2,
internal oblique line; 3, position of needle at Superior margin of lingula; 4, most suitable
length of needle behind lingula (a further advancement would result in failure); 6, position
of needle, 1 cm. above level of masticating surfaces of molars; 7, lingula; 8, inferior dental
foramen. (After Fischer.)
“The two halves of the mandible, when viewed from in front, grad-
ually diverge toward the angle, so that the inner surface of the angle
with the mandibular foramen is inclined posteriorly and pharyngeally,

















THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 5.I.9
and appears to be entirely covered by the internal oblique line. (See
Figs. 181, 182, 185, 186).
“Position of Syringe.—The line of the body of the mandible is not
horizontally continuous in a straight line to the ascending ramus,
but presents a lateral bulging at the angle, so that the internal surface
of the ascending ramus is not parallel with the lingual surface of the
body of the jaw. (See Figs. 181, 185, 186.) The ramus opens pos-
teriorly. (See Figs. 183, 184, 185, 186.) If, therefore, the oblique
}
MºWº% g e §gº.
§ Cºlºid Pºlygºid Wºº
º N º process fossa \\ W.
Ridge \ º !" \\ § /./
\\\\". § ſº
| Coronoid
| process Coronoid
process
Retromandibular
groove
Line of reflection of
mucous membrane
Ascending
70,777,745
Cancellous alveolar
margin
ºxes
º
ſ {
º: l |
§– Angle
º/
%
t §
| §
N | & ºš
|\ |\ || /?
A ſlº { || || º / % º
yy s § § Jº . . § g gº
23%, W. **- ºsº, * * * * * ‘. º Oblique line
S$$$... . . . St. 32: 3:2%: º
§§ S -2: ;2% º &
-š-š---º Line of reflection of
----s == - mucous membrane
š # *%
*s sº * º
S 2 à 2. tº.
s # = 2. %
3 #~2%. Mental (incisor)
º- **Elea:
__. Nº foramen
a-skä”
Canine fossa Mental protuberance
Fig. 185.-Points of injection for mucous anesthesia in external surface of mandible.
The crosses indicate points of injection; small arrows, direction of needle; two large arrows,
direction of needle for injection in mental foramen and fossa. On the internal surface of
the ramus are marked the points for injection at mandibular foramen. (After Fischer.)
foramen is to be reached, we must never advance posteriorly parallel
with the teeth (Figs. 187, 188), but with the internal surface of the
ramus, at an acute angle to the plane of the teeth (Figs. 183, 187,
188, 189). If the direction of the ascending ramus is projected ante-
riorly, the line will meet with the other side in the canine region, be-
tween the canine and the bicuspids (Figs. 183, 184, 187, 188, 189).
Thus, in order to reach the inferior dental foramen the syringe must
be rested behind the canine on the opposite side. (See Figs. I83, 187,
























52O LOCAL ANESTHESIA
|
188, 189.) The foramen in adults is situated at a higher level than in
children. The horizontal direction of the needle must, therefore, be
modified in children by slightly lowering it posteriorly and pharyngeally
in order to reach the foramen directly. (See Fig. 182, A, B, C.)
“Character of the Tissues.—The character of the tissues encountered
is most favorable for injection in the oblique foramen.
“The temporal and external pterygoid muscles are inserted above,
the internal pterygoid below, the foramen, leaving the close proximity
of the foramen free from muscular fibers. (See Fig. 190.)
i
Fig. 186.-Lingual points of injection for mucous anesthesia of mandible. Crosses
indicate points of injection; arrows, direction of needle; black line of dashes, the angle of
the ramus to the body of the jaw. (After Fischer.)
“Instead we find considerable accumulations of loose interstitial
connective and adipose tissue, which readily absorbs and retains the
injected solution. (See Fig. 191.)
“This cushion of tissue is situated about 1 or 2 cm. above the al-
veolar process.
“Technic of Injection.—With the left index-finger the anterior
portion of the base of the ascending ramus is palpated, the patient’s
mouth being opened widely. Two very marked bony ridges are felt
here, one anterior external, the external oblique line, and one pos-
terior internal, the internal oblique line (Figs. 183, 184, 187, 188).
|



THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 52I
Between these two lines at the root of the ascending ramus a shallow
bony grove is situated, which might be properly called the retro-
malar fossa, into which the palpating finger-tip sinks (Figs. 183, 187,
188, 189.) The mucous membrane is caved in over this fossa in some-
what triangular shape; Braun, therefore, calls it the retromolar triangle.
“The internal oblique line is fixed with the finger-nail, and the
needle inserted close to the nail into the mucosa near to, yet not im-
mediately at, the edge of the bone (Figs. 183, 187, 188).
Fig. 187.-Position of syringe for injection at mandibular foramen: Ix, External oblique
line; 2x, retromolar fossa; 3x, internal oblique line; 4, mandibular foramen behind lingula;
5, incorrect position of syringe, parallel to teeth. (After Fischer.)
“The syringe is pushed forward horizontally and posteriorly from
the canine, on the opposite side along the internal Surface of the man-
dibular half to be anesthetized (Figs. 183, 184, 187, 188, 189).
“The needle should be introduced to a depth of not more than
from 1.5 to 2 cm. under the mucosa, lest it advance too far beyond the
foramen and the correct point for the disposition of the Solution be
missed. '

522 LOCAL ANESTHESIA
“The injecting solution is then deposited, beginning to inject soon
after insertion of the needle, in order to anesthetize the lingual nerve
at the same time (if this be desirable). The bulk of the solution, how-
ever, should be injected in the mandibular foramen.
“Insertion of the Needle.—The point of the injection is selected so
that the needle is introduced in the mucous triangle, about I cm. above
the level of the masticating surfaces of the molars (Figs. 187, 188, 190,
I92); in children and youthful persons, advancing a little farther pos-
teriorly while slightly lowering the needle; in old persons, slightly
raising the long needle (Fig. 182).
... • Inferior dental nerve
- Inferior dental artery
LSection through ascend-
ing ramus
Lingual ºne--0
__--Retromolar triangle
w Sº
|\\ \
* -
\\\ A SJMucous covering
; W ------Internal oblique line
Mylohyoid ridge----- . . \\ Y--External oblique line
x|- \. _Point of contact of syringe
with third molar
-- Third molar
w
* ~
*s
* =
." ~T
Fig. 188.-Horizontal section through ascending ramus. Diagram showing position
of syringe and needle: i, Eminence of internal oblique line; e, eminence of external oblique
line. (After Fischer.)
\
~\- Correct direction
* = of needle
Direction of dental arch
“Difficulties.—The technic of this form of injection offers some diffi-
culties, which, however, after some practice are easily overcome;
above all, it must be observed that the insertion of the needle is made
not directly at the edge of the bone in the internal oblique line, but
somewhat lingually from the bone. Behind this internal ridge the
bony substance bulges still farther lingually, running over into the
lingula after having first formed a second convex excrescence (Figs.
184, 187, 188).
“After the correct point of insertion, about I cm. above the level
of the masticating surface of the last molar, has been found the oblique
foramen is reached, just above the lingula, with the needle (Figs. 184,
187, 188). º



THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 523
“The distance from the anterior margin of the internal oblique line
to the posterior margin of the lingual is about 15 mm.
“During the injection it is best, as has been correctly emphasized
by Williger, to rest the Syringe barrel on the bicuspids or between
Frenum labii
ºS * superioris
*2%NSe 2.Gingiva
º NS -Upper lip
PA”
& § ). ...T Upper dental arch
}\r \
- \ _ Hard palate
* Anterior pillar
A Posterior pillar
H. Tonsil
ſºlº Point of insertion of
needle in retromolar
fossa
%
#7 ". Gingiva
Frenum labii inferioris
S- *~
Lower lip
Points for injection in mental fossa
Fig. 189.—Oral cavity, widely opened. The solid black line indicates the correct
position of the syringe for mandibular anesthesia. The arrows at the anterior portion of
the mandible indicate the points of insertion of the needle in the reflection of mucous mem-
brane for injection in canine fossa. (After Spalteholz.)
the canine and first bicuspids of the opposite side, thus securing a
certain support for the syringe and an indication for the correct level
for the insertion of the needle. (See illustrations.)
“Management of the Needle.—After insertion the needle is advanced







524 LOCAL ANESTHESIA
~
to the bone without entering the peritoneum (Figs. 187, 188). A
certain touch is soon acquired as to whether the needle is being ad-
vanced in the correct direction, not too far pharyngeally, yet closely
enough to the bone. If, in case of a very sharp angle of the bone, the
periosteum is found to offer resistance, even though moderately, the
needle should not be advanced any farther, and under no condition
use force, else the needle bores into the periosteum of the bone and is
Sure to break. It is best to carefully withdraw the needle for a short
distance, and, after slightly altering its direction pharyngeally, to ad-
vance again posteriorly.
“The bone should not be reached before the needle has gone for a
certain distance from the point of introduction (Figs. 184, 187, 188),
yet not immediately at the internal oblique line, as has already been
demonstrated. -
External pterygoid m.
Temporal m. -
Genioglossus m.--5
Geniohyoid m.
Digastric m. Mylohyoid m.
Fig. 190.-Origins and insertions of muscles upon inner surface of mandible. (Rauben and
Ropsch.)
“Injection of Solution.—The solution should be emptied slowly
and carefully, beginning immediately upon insertion of the needle in
order to anesthetize simultaneously the lingual nerve (should this be
desired—Author), which descends in front of the inferior dental nerve
(Fig. 188). The bulk of the solution, however, is deposited at the
oblique foramen. Penetration of the muscles in this region is out of
the question, as has been shown above (Fig. 190). g
“Neither is there any danger of puncturing the artery, which pos-
sesses thick walls, is protected by the lingula, and has enough space to
evade into the loose surrounding tissues or into the depth of the in-
ferior dental canal (Fig. 188). The corresponding vein is arranged
around the artery in form of an intricate plexus and is equally well
protected. The injection in the left ramus offers somewhat greater



THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 525
difficulties. While in the right oblique foramen the retromalar tri-
angle is palpated with the left hand and the injection is made with the
right, it is advisable to use the left hand for injection on the left side,
according to Peuckart’s suggestion, palpating and fixing the retro-
malar triangle with the right.
“Effect of Injection.—About three minutes after the injection the
patient perceives a slight tingling in the lip and tongue on the in-
Occipitofrontal m.
A poneurosis
Temporal fascia
Temporal m.
Zygomatic arch
§e
&
! §: : e §. te
Sº % *7-External pterygoid m.
%, , Q º
}///
§NW. \ 31' % # ſ/ Lateral plate of ptery-
Parotid gland—ºft/ . .8° Prºcess
- § *::\} § / Adipose tissue
º, # / Internal pterygoid m.
Masseter m. Mandible
Fig. 191.—Frontal section of temporal region. The solid black line indicates the
aponeurosis, the dotted line the periosteum and temporal fascia. At the mandibular
foramen a mass of adipose tissue is observed which offers no resistance to the advance
of the needle. (After Merkel.)
jected side. The tingling is the best indication as to the correct execu-
tion of the injection.
“The sensation gradually increases, and a certain numbness of
the entire half of the jaw ensues. The lip on the anesthetized side
depends slightly, exhibiting symptoms of partial paralysis, and the
patient usually feels as if it were greatly swollen. Difficult deglutition





526 LOCAL ANESTHESIA
is absent if the technic has been executed correctly. Its presence indi-
cates that the injection has been too far pharyngeally and posteriorly.
The concomitant symptoms persist for about one hour, after which
they gradually subside, the former normal condition being re-estab-
lished after about three hours.”
For anesthesia of the hard palate and roof of the mouth advantage
can be taken of the points of emergence of the palatine nerves upon
the hard palate. (See Fig. 161.) These can be easily reached by in-
Glossopharyngeal n. Internal carotid artery
• and pneumogastric n.
Cervical ganglion of supe-
rior sympathetic trunk
•)
ſ
ſ -
3|| º 3.
|%i
Internal jugular vein % % \
and glossopharyn- (j\% % w
geal n. - \% % º
\\ à %
\ \\%2% Atlas with tebral
Y-WA 㺠s with prever
Parotid fossa A31% fascia
Rectus capitis anticus
Posterior focal vein º major and longus
|> ºf \ colli major
º - CY Hºyº-ºº:
External carotid artery sº
Parotid gland Hypoglossal m.
|
º
ſ
|
2.º
Çſº
Facial nerve-iſſ %
and nerve %
%
zºº
ÇAX&%
Masseter m. s “ ©º
Internal pterygoid m. - Tonsil
Internal maxillary artery and vein
Fig. 192.—Horizontal section through lower portion of oral cavity. Relationship
of lower teeth to ascending ramus and mandibular foramen. The large arrow indicates
the correct position of syringe and needle for mandibular injection. (Corning.)
jections over the opening of the anterior and posterior palatine canals,
the anterior just behind the incisor teeth in the middle line and the
posterior just to the inner side of the last molar tooth, where the hard
palate joins the alveolar process, in each case making the injections
deep down in close contact with the bone.
In using this method it will often be necessary to secure perfect
anesthesia to block the posterior palatine nerves on both sides, as
the branches from each side cross over beyond the middle line.
The tongue can be anesthetized by blocking the lingual nerve with .












THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 527
a paraneural injection. This nerve lies quite superficial under the mu-
cous membrane, where it crosses from the ramus of the jaw to the base
of the tongue; if the tongue is drawn forward and to the opposite side
this fold of mucous membrane is put upon the stretch. A needle
passed just under the surface of the anterior edge of this fold to a
depth not to exceed # inch, and # to 1 dram of solution No. 2 (o.5o
per cent. novocain) injected in this position will block the nerve; the
opposite side can be similarly treated, thus anesthetizing the anterior
two-thirds of the tongue, the field of distribution of the lingual, when
Fig. 103–Sensory innervation of the mucous passage of the head and throat. (Hasse.)
Nerves shown in Roman characters, branches of the fifth in Arabic. (Härtel.)
resections or any operations needed can be performed. The floor of
the mouth receives nerves from other sources, and will have to be
separately anesthetized if the operative field encroaches upon this
region.
The alcoholization of nerves for the treatment of neuralgia had its
beginning in experiments undertaken by Schlösser in 1900. He found
that the injection of sensory nerves with 1 to 2 c.c. of 80 per cent.
alcohol produced a burning pain of momentary duration, followed after
a few minutes by numbness and anesthesia, which in the course of a

528 LOCAL ANESTHESIA
week disappeared and was followed by a return of tactile sensation,
but the pain sense remained absent. Following these experiments
Schlösser's first report on the treatment of neuralgia appeared in the
“Transactions of the Heidelberg Ophthalmologische Gesellschaft,”
1903. Unfortunately, he does not state very clearly his technic, for
the reason, as stated, that this method of treatment had not yet been
given sufficient trial to determine its merits. Somewhat later he
goes more into detail and describes a transverse puncture from be-
neath the zygoma; he also describes a method for reaching the fora-
men ovale with a finger in the mouth, locating the pterygoid process
behind the tuber maxillare. The needle is entered through the mouth
and pushed through the mucous membrane, under guidance of the pal-
pating finger, and advanced some distance upward and backward
beyond the external pterygoid plate to the region of the foramen ovale.
In the buccal method of Ostwalt for reaching the foramen ovale he
enters the needle through the mucous membrane at a point opposite
the last molar tooth, and advances it along the external pterygoid proc-
ess toward the foramen ovale.
In the buccal route of Offerhaus he determines the position of the
foramen ovale from the last molar tooth as representing approximately
an angle of 130 degrees, in which direction he enters the needle.
It is possible that by the intrabuccal routes of Schlösser, Ost-
welt and Offerhaus the ganglion was often reached, but never with
the same degree of certainty as by the Härtel route. Härtel uses
practically the same route, except he adopts the more aseptic point
of puncture upon the cheek, and safeguards the passage of the needle
in the right direction by advancing it at determined angles and to a
definite depth, and from a position certainly less trying and unpleasant
to the patient. -
Among the first to report direct injections of the gasserian ganglion
was Harris (Royal Soc. of Med. Neurolog., Feb., 25, 1909). He
demonstrated the successful injection of the ganglion with his technic
by using colored solutions upon the cadaver. This line of puncture
varies little from that used by him to reach the trunk of the third
division beneath the skull, only that the needle is entered at a lower
level, so that its axis will be more nearly that of the foramen ovale.
A line is drawn from the ala of the nose to the incisura notch (of the ear).
This line on the average skull passes over the lower border of the sig-
moid notch of the inferior maxilla with the mouth closed.
The needle is entered on or slightly below this line and below the
midpoint of the zygoma, and directed obliquely upward and inward
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 529
through the sigmoid notch, and feels its way along the base of the skull
toward the foramen ovale, within which the needle is felt to slip. By
injecting the ganglion by this route there is danger of wounding the
Cavernous sinus or carotid artery within the skull. (See Anatomic
Illustrations.) - -
The transverse methods of approach to the third division of the
fifth nerve by Alexander, Patrick, Kiliani, and others are practically
the same with minor modifications, and are well illustrated by the pro-
Cedure of Braun, which, to the author, seems established on some-
what better anatomic lines.
Dr. Hugh T. Patrick, in speaking of deep alcohol injections made
beneath the foramen ovale and rotunda for trifacial neuralgia, after
an experience of over 3oo injections with 85 per cent. alcohol, states:
“The danger of the operation is as nearly nil as can well be. I know
of no fatality, and think none has ever been recorded, nor have I heard
of a single case of infection.”
The only complications he had which would be at all likely to occur
when injecting a non-irritating anesthetic solution into these parts
was the rare appearance of a hematoma. As Patrick uses a rather
large needle for these injections, the likelihood of injuring the vessels
is greater, but if a small caliber needle with blunt point, such as is
ordinarily used for spinal puncture, is substituted, this danger will be
largely overcome.
In making these injections it is best to use specially constructed
needles and syringes. The needle should be of Small caliber and
strongly made and with a short beveled point, combined with aids
for determining and controlling distance. Such an outfit, as designed
by Härtel, is seen in Fig. 233.
The area on the base of the skull within which lie the foramen
rotundum and foramen ovale is within a very limited space, yet their
approach is very often surrounded by many difficulties, which may not
be the same in any two skulls, due to the individual variations in the
Osseous arrangement of the parts, For this reason no method of
approach that has yet been devised, or is likely to be, will guide us to
the desired point with unerring accuracy, and no method of computing
these variations in the position of the basal foramina from a study of
the variations of the external configuration has been found reliable.
Much study has been spent upon this subject and many skulls meas-
ured, with a view of obtaining some accurate information to guide us
in the proper direction. Many ingenious methods have been devised,
the more notable and recent of these are the Offerhaus and Härtel
34
53O LOCAL ANESTHESIA
routes, which, added to the information previously possessed on this
subject, have placed our methods of approach on a more accurate foot-
ing, and now enable us in the great majority of cases to make intra-
neural and even intraganglionic (gasserian) injections, instead of con-
tenting ourselves with paraneural injections, which were often the best
we were able to accomplish in the past in reaching the third division
of the trigeminus.
The problem of reaching the second division with accuracy was
solved by Matas, in 1898, by the intra-orbital puncture of the foramen
rotundum, although this has by some writers been erroneously attrib-
uted to Payr.
The foramen rotundum lies within the sphenomaxillary fossa, at
the point of junction of the sphenomaxillary and the pterygomaxillary
fissures. The foramen ovale, at the base of the skull, lies just behind
the zygomatic fossa at the base of the external pterygoid plate.
Either foramen may be approached from in front or laterally—
in the case of the foramen rotundum, by the Matas route through the
orbit, and for the foramen ovale by several routes through the mouth,
or the Härtel route through the cheek. The lateral or transverse
approach to either foramen is from above or below various points on
the zygoma through the temporal or zygomatic fossae.
Viewed from below (Fig. 196) we find the region of the foramen ovale
to have the following points worthy of note. Beginning forward and
laterally, on the great wing of the sphenoid at the pterygoid ridge, and
proceeding downward, backward, and inward toward the foramen,
we see a slightly concave surface at the base of the external pterygoid
plate, the area of attachment of the external pterygoid muscle; this
surface is perfectly smooth, and leads downward, backward, and inward
over a smooth convex rim of bone into the foramen ovale.
Approaching the foramen from below and in front, along the ex-
ternal surface of the external pterygoid plate, we find this surface
likewise smooth and even and leading downward and backward into
the foramen ovale.
The external pterygoid plate, like the other parts concerned here,
is subject to a certain range of variations. Some of these, met with
by Härtel, are shown in Fig. 194.
This information is useful in the following way: If the needle is
advanced from in front through the cheek or mouth, and its point
carried rather low, meeting the external pterygoid plate, it must be
advanced upward and backward along the smooth surface, feeling its
way to the foramen; if the point is directed high up, and first meets the
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 53I
under surface of the Sphenoid at the base of the pterygoid process, it
must be advanced backward and inward over the bone, and, as this
Surface slopes downward, backward, and inward as the needle success-
ively feels its way backward, it must be gradually withdrawn in follow-
ing the downward slope of the bone.
The posterior margin of the foramen is formed by a sharp ridge of
bone, which is directed downward, forward, and outward, running
from behind, near the foramen spinosum, forward and inward, to be
Fig. 194.—External lamina of pterygoid process and foramen ovale on right side of
skull seen from the side: a, The external lamina and spina angularis are grown together
and form the foramen Civinini; b–f, broad form of external lamina; g—l, narrow form of
external lamina. Between the foramen ovale and external lamina can be seen more or less
of the deeper situated parts forming the base of the skull (pterygoid and scaphoid fossae).
(Härtel.)
lost in the pterygoid fossa. On a plane just back of the foramen ovale
we find the sharp irregular spinous process of the sphenoid, which gives
attachment to the internal lateral ligament of the jaw and tensor pala-
tine muscle. The foramen spinosum is seen running through the
spinous process for the passage of the middle meningeal artery; it
usually lies just behind and external to the foramen ovale.
At the apex of the petrous portion of the temporal bone, and inter-
nal and behind the foramen ovale, is the foramen lacerum medium.

532 LOCAL ANESTHESIA
Slightly internal to the foramen spinosum, and behind the foramen
ovale, is seen the canal for the Eustachian tube and tensor tympani
muscle; the anterior external boundary of this canal is formed by the
short ridge of bone which forms the posterior internal margin of the
foramen ovale, consequently it is seen that the Eustachian tube and
middle meningeal artery lie on a plane just posterior to the foramen
ovale. The posterior internal wall of the Eustachian canal is formed
by the hard, rough, and uneven convex surface of the petrous portion
of the temporal bone. The situation of the Eustachian tube just back
of the foramen ovale is of much importance. If the point of the
needle is advanced too far posteriorly, and comes in contact with the
rough and irregular surface bordering this tube, it should be at Once
recognized and withdrawn and redirected more anteriorly. A punc-
ture of the Eustachian tube is recognized by its producing a sharp pain
in the ear, and if the solution is injected it escapes downward into
the pharynx.
Just back of the Eustachian canal, in the petrous portion of the
temporal bone, is seen the carotid canal, usually lying in a line directly
back of the foramen ovale from # to # inch, the Eustachian tube lying
between. Directly back of the carotid canal is the jugular fossa.
The internal jugular is formed within the jugular foramen by a junc-
ture of the inferior petrosal and lateral sinuses. The three nerves—
glossopharyngeal, pneumogastric, and spinal accessory—lie in the
above order in front and to the innerside of the jugular within the
foramen.
The distance of the carotid foramen from the foramen ovale is,
according to the measurements of Härtel, minimum, 8 mm., maxi-
mum, 17 mm., with an average of 12.7 mm., and from the foramen
ovale to the jugular foramen 15 to 28 mm., with an average of 20 mm.
(See Table II, No. 4.)
It is seen from the above that the entire bony surface lying in front
and to the sides of the foramen ovale is smooth, and even while the
bony surface behind it is rough and irregular; consequently, if the
needle as it is advanced feels the smooth undersurface of the sphenoid
it means we are still within safe territory, and that the needle must
be gradually insinuated backward, but if we are come into contact
with the rough and irregular surface lying posteriorly we are on
dangerous ground and the needle must be withdrawn and reinserted
further forward.
Lateral to the foramen ovale, on its outer side, is seen the eminentia
articularis, and on its outer extremity, on the lower margin of the
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 533
zygoma at its root, is seen the articular tubercle, which is usually on
the same lateral plane as the foramen ovale.
For a further description of the anatomy of this region I quote the
following from Härtel, who, in his classical presentation of this subject
in the “Archiv. für Klin, Chir.,” vol. c, 1912, in a discussion of the
various routes, with a presentation of his own method, contributes an
exhaustive study of this region which must remain for all time as
a monumental contribution to the Surgery of the head, and through
whose kind permission I am permitted to quote him in this chapter.
In conjunction with the description of this region, see Fig. 196.
O
s e 7 e o ſo 11 mm
Gº | Q | Q | QºS wº -
C C Clee
O |O |G| |QC
O || |O
O

Fig. 195.-Schematic representation of the differences in size and shape of the foramen
ovale obtained from 116 examinations, shown in natural size. (Härtel.)
“The form and size of the foramen ovale vary extraordinarily.
Scarcely a skull is found whose foramina ovalia are equal to each
other. The shape varies from the small longitudinal slit to the circu-
lar form; there occur also transverse, oval, as well as occasionally roll
and kidney forms. The length, on the average 6.9 mm., varies between
5 and II mm. (Table II, No. 1), the breadth between 2 and 7% mm.,
with an average of 3.7 mm. (Table II, No. 2).
“The accompanying Fig. 195 shows the size relationships of the
foramen ovale found by us in II6 examinations. According to this,
the way through the foramen ovale must always stand open for the
cannula (o.8 mm. thickness); still, according to my experience, a
534 LOCAL ANESTHESLA
lacerum or both (Table II, No. 3).
breadth under 3 mm. means a difficulty in puncturing. We found
this unfavorable breadth in 8 per cent. of the skulls examined (Table
II, No. 3). Occasionally the foramen ovale is not bony all the way
around, and stands in open connection with the foramen spinosum or
***
w
.**
& |
§
*
->
Ç Ant palotine/arra
Q y is: ſº
g %ransmier Zeff Wºo-palat. n.
HTansmits Ant palat vess.
º N #: º %ansmity right Naropalat, n.
- Qº §e, J" 5
- ł te - ſ:
eeet sory pazztºne
Mora mzzºna.
Post.Warsal Spine.
a 2 ºf º O & U W J E as
Hamular proc
Sphenoid proc. of Palate.
#’terygo-palatine 6.
TEN 80 R T YMP ANI,
Zaryngead Spine for sur cowcraids
Sºtº of E. # * ... . . . .2. Aº
A , ex- gº
& w-z-
lar aro R Y Pſy'AN 1-
ºr.&rerºemparcerºus.
Canal for Arnold!3 as
asricular fºrture.
|
&º
... sº :
iss
§§§
§
§
§§
Nº.
&
Fig. 196.-Base of the skull, external surface. (After Gray.)
On the other hand, a multiple
foramen ovale, which Offerhaus found unusually frequent (5 per cent.),
we could not observe in any case, nor are any similar cases mentioned
in the anatomic literature (Poirier, Testut).
On the other hand,

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 535
atypical venous emissaries (foramina innominata, venosa, Vesalii)
are frequent in the neighborhood of the foramen ovale.
“The entrance to the foramen ovale is overhung on the anterior
end by the lamina lateralis of the pterygoid process; behind, by the
Fig. 197-The development of the foramen Civinini from the ossification of the
Lig. pterygospinosum. (Photo from a specimen in the Anatomical Collection): 1, For-
amen ovale; 2, foramen Civinini. (Härtel.)
spina angularis. In cases of strong development these ridges of bone
are united by a ligament which many times ossifies (ligamentum
Civinini spina pterygospinosum) (Fig. 194). This ossification need not
Fig. 198–Sagittal section through the foramen ovale. The section lies in a somewhat
obliquely placed vertical plane corresponding to the direction of the needle to reach the
ganglion: 1, Impressio trigemini; 2, petrous bone; 3, carotid canal; 4, occipital bone; 5,
great wing of sphenoid; 6, planum infratemporal; 7, needle in foramen ovale. (Härtel.)
present a hindrance to puncturing. If the foramen ovale lies medially
from the foramen Civinini, then the transverse way (from beneath the


536 LOCAL ANESTHESIA
zygomatic arch) must first go through the foramen Civinini in order
to reach the nervus mandibularis, which in practice must involve
difficulties. Likewise the way from in front through the cheek or
mouth can be obstructed by an Ossified ligamentum pterygospinosum
accompanied by narrowness of the foramen ovale. However, we have
found this relationship only once among 134 examinations (Table II,
No. 3), while we observed the ossification itself 9 times (7 per
cent). The distance of the posterior margin of the foramen ovale
from the foramen spinosum is also subject to great variation; it varies
between o and 6 mm. (Table II, No. 4). The shorter this distance,
the greater, theoretically, is the danger of injuring the arteria meningea
media. We avoid this danger in puncturing as we seek the foramen
from before, always feeling our way very gradually.
“The foramen ovale presents really not a hole, but a bone-canal
of about 1 cm. in length (Testut and Jacob), which penetrates the wing
of the sphenoid bone (at this place abóut 7 mm. thick) in diagonal
direction in front from below laterally; behind, upward toward the
median line. If we observe the orifice of this canal from the under
surface of the skull, then we find on the anterior outer side of it and
on its long side a smooth curvature gradually passing over into the
planum infratemporale, while the posterior inner circumference is
bounded by a sharp ridge which rises sharply posterior to the fissura
sphenopetrosa, the bed of the tuba Eustachii. Therefore, for a con-
venient introduction of the cannula the anterior outer long side offers
the best chances, for here the needle glides over a broadly curved
bone-surface and catches the foramen from the broad side (Fig. 198,
diagonal vertical section through the left sphenoid bone and petrous
portion of the temporal bone). In addition I might remark that the
planum infratemporale in the cadaver skull, with soft parts in situ,
always offers to the puncture needle a completely smooth and hard
bone surface, while the vicinity of this planum posteriorly and inwardly
is covered unevenly, roughly, by cartilage and fibrous tissue, and,
therefore, gives to the needle the characteristic feel of a rough, grating
resistance. We must come into the foramen on a smooth, hard, bony way;
if we feel the grating unevenness we are wrong, and must retreat forward
and outward.
“This deviation of the needle on the inequalities of the pyramid of
the petrous portion of the temporal bone, of the foramen lacerum, or of
the fossa pterygoidea can easily occur if one confines himself exclusively
to the angle between the lamina externa of the wing of sphenoid and the
planum infratemporale. One should consider always that the fora-
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 537
men ovale is located outwardly from this angle, and that in many
cases the lamina externa is so small that between its posterior margin
and the foramen ovale a considerable portion of way still remains
open, which may be as large as 8 mm. Figure 194 shows some skull
variations which illustrate this relation between the foramen ovale
and the pterygoid process. If one seeks to find a measurable expres-
sion for these relations by measuring the breadth of the outer wing
of the sphenoid bone at the base, in other words, the distance of its
anterior margin from the foramen ovale, then the numerical relations
described in Table II, No. 5, result.
- -
Fig. 199-Härtel method for the injection of the gasserian ganglion. Base of skull
seen from above with the needle passing through foramen ovale to the impressio tri-
gemini. (Härtel.)
“The rule, therefore, which is to be observed for the sense of bony
resistance from the planum infratemporale to the foramen ovale is as
follows:
“One goes gradually from before backward, maintaining a posi-
tion laterally from the lamina externa, and never deviates from the
smooth, hard substratum. In so doing the point of the needle de-
scribes an outwardly convex curve.
“Let us now follow the way further into the skull. For the ac-
curate puncture of the ganglion Gasseri we have established the
requirement of adherence to the so-called axis of the trigeminus; that
is, a straight line going from the middle of the impressio trigemini




538 LOCAL ANESTHESIA
of the petrous portion of the temporal bone through the middle of the
foramen ovale (Figs. 199, 200). Only a cannula introduced into the
skull in this direction avoids collateral injuries of the tissues adja-
cent to the cavum Meckeli (Figs. 207, 208), namely, of the sinus
cavernosus, of the carotis interna, of the sinus petrosus superior, and
of the brain. If, as we have said above, the foramen ovale is not a
simple hole, but forms a bone-canal about 1 cm. long, so we find now
that the long axis of this canal corresponds to this axis of the trigemi-
nus; in other words, passes parallel to the anterior surface of the
pyramid of the petrous portion of the temporal bone (Fig. 201); if
º
Fig. 2do.—Same as Fig. 199, seen from the side, showing needle passing into foramen ovale
between ascending ramus of lower jaw and maxillary tubercle. (Härtel.)
it should not do this, and, for example, should pass more steeply (Fig.
201, b), then the cannula would penetrate, not into the ganglion, but
through the dura into the temporal lobe; if it passes more on a level,
then the danger exists that the cannula from above, through the fora-
men lacerum, may prick the carotis interna. The latter situation
we never found; the former, less dangerous, situation, very seldom (3
times in 114 examinations); and even in these cases of incongruence
between the inclination of the pyramid of the petrous portion of the
temporal bone and the long axis of the canal of the foramen ovale
it suffices practically, if the needle, coming from below outward, then
upward and inward, traverses the canal of the foramen ovale in diago-

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 539
nal direction, and thereby arrives in the direction of the inclination
of the petrous portion of the temporal bone (Fig. 201, b, c, d).
A
Fig. 201—Schematic representation of the trigeminal axis and the direction the needle
should take to the gasserian ganglion: a, Normal type. The long axis of the bony canal
of the foramen ovale and the inclination of the petrous bone lie in the direction A, B; b,
occasional variation. The long axis of the bony canal of the foramen ovale A, B stands
more steeply than the inclination of the petrosa C, D. (Härtel.)
“The question is of importance as to how deeply we may go into
the foramen ovale with the needle. We must, therefore, measure the
Fig. 202.-Projection upon the upper jaw of the different axes of entrance to the
foramen ovale, showing their variability: a, Medium steep; b, flat; c, steep; d, overflat;
e, oversteep. (Härtel.)
distance between the superior margin of the pyramid of the petrous
portion of the temporal bone and the posterior inferior margin of the


54o LOCAL ANESTHESIA
foramen ovale, and we find (Table II, No. 6) a minimum of 14 mm., a
maximum of 23 mm., and an average of 19 mm. The minimum (1.4
Fig. 203–Projection of an equally steep axis upon upper jaws of various height: a, a',
Short upper jaw, axis appears steep; b, b’, medium high upper jaw, axis appears medium
steep; c, c', high upper jaw, axis appears flat. (Härtel.)
cm.) is the standard; if we go deeper, we run the danger of puncturing
through the chief trunk of the trigeminus through the cisternae of
- *
Fig. 204.—Position and size of area of skin anesthesia for injection of gasserian ganglion.
(Härtel.) -
the posterior cranial fossa (cisterna pontis). This has actually hap-
pened to us in the living subject, and emission of fluid resulted. One
secures, if one immediately draws the needle back somewhat and then




THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 54I
Fig. 205-Härtel route, showing axis of needle to pupil of eye when viewed from in
front and to articular tubercle at base of zygoma when viewed from the side (photo from a
cadaver. (Härtel.)
Fig. 206.-The carotid region and the chief structures. Note the relation of the internal
jugular vein, the common carotid artery, and the pneumogastric nerve. (Campbell.)
injects slowly, a very beautiful and certain conduction anesthesia of
the chief trunk of the trigeminus. This deep procedure is always to


542 LOCAL ANESTHESIA
be warned against, for thereby one runs the danger of pricking the
sinus petrosus superior, or of injecting the solution, instead of into the
ganglion, into the posterior cranial fossa, which has collateral mani-
festations (vomiting) as a result.
Groove fºr Super longitudyinue
Grooves for Antºr MenºngealA
Ferameº tºetºm-
Slit fºr Wººl mer”—
Groºve fºr Narrºl.”—
Anteriºr Ethnoudal For-
* -
3\\\\\
# º- º
- -
Olfact &rºove-wiriº
factory *y-2: Lerºriſing
Sºena.
aerie Foramen ºf SA’ſ eno, º
Optic Groove— —r: º
Olivary 2-—º
Anterior clinoid prea—º-º
Middle clinoid proc: º
Posterior Clinoid proa- .nº sº
Groove fºr 63 nerve
Forº laeerum medium.
Örüfºre ºf Carotta Canad
Depression fºr casterian Ganglion
-
Meatur Auditor. Internar–º
it for Dura-Mater
ºp. Petrosal groore—
Fºr. Tarceram pasterius
Auterior Condyloid. Fºr
Aqueduct. Pertibuls
Pºrterior condyloid Fer
.Martoºd Fºr Mag ºn tº ºn
Pºrt. Meningeal drooves
Fig. 207.-Base of the skull, inner or cerebral surface. (After Gray.)
“If we now follow the axis of the trigeminus already mentioned,
then we find that it traverses the fossa infratemporalis, and passes
on exactly in the middle line between the ascending branch of the
lower jaw and the tuber maxillare. For choosing the puncture point
it is important to know where the lateral projection of this axis on the
upper jaw cuts the alveolar margin. This point is dependent on two











THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 543
different factors, namely: (1) On the more or less steep course of the
axis of the trigeminus; (2) on the situation of the upper jaw.
superior sagittal sinus
optic nerve nasofrontal rein . º: inferior sagittar sinus
bulbus druli º - - anterior ... anterior meningral art.
. rircular sinus fanterior interravernons
ºwtir nerve
Rertus orith superior x
Levator palpebrae superioris x -
vortirose rein internal mrotid art.
long riliary reins -
larhymnſ rein º anterior ºr of middle
º, meningral art.
-
Zº
* / * / .
ophthalmir artery ophthalmer nerve
----------
ophthalmic rein-, º, -
sphenoparietal sinus -
hypophysis -
(diaphragma sellae, --,
covernous sinus A.
- armonotor nerve
maxillary nerve
--
intern, rurotid
- plexus
-º-º-º-º-º-e
--tº-
meningear art
...great sanerſ.
metros. meree
ºwner, tyinnan art.
less, simp.
l
l - petr, nerve
- -- - superf. petros.
º br of middle
º meningeal
º ºff.
-
f
H.
|
-
root of trige-
minal nerve
- - - - -
rirrufar sinus - - - - Nº. ;
osterior - - - - - - º petrosa
º raw.) --- sinus
inter- º º - root of
transverse sinus K º Z facial nerve
-
- - - root of aroustic
basilar plexus! ". - ----e.
- - - - L
ſentarium- - - ºf -
cerebelli - - - -
trans-en-seº - transverse sinus
------
root of glosso- .
pharyngeal nerve
root of vagus nerve
root of accessory nerve
roots ºf hypoglossal nerve”
vertebraſ artery x
--
encºphalir dura mater , heningeal br. of occipital art.
great cerebral vein - - - wroof ºf abducent nerve
inferior sagittal sinus * - - . - -- roof-of-ahressory nerve
rsinus a ---- mening, br.
aerebrix *** medalla º art.
sagittal
× oblongatax
Fig. 208-The dura mater with its arteries and sinuses, the veins of the orbit, and the
course of the twelve pairs of cerebral nerves through the dura mater. The left orbit has
been opened. Upon the right the tentorium cerebelli has been removed, the commence-
ment of the transverse sinus opened, and the dura mater excised along the emerging nerves
and the middle meningeal artery. X Meningeal nerve and anastomosis with the spinal
nerve; *X = cut edge of tentorium. (Sobotta and McMurrich.)
“According to Fig. 202, the steeper the axis is the farther behind
the upper jaw it strikes; on the other hand, according to Fig. 203, an
axis with equally steep course will reach a more or less high built up-
per jaw farther forward or behind, and so appear more level or steeper.





































































544 LOCAL ANESTHESIA
Lining membrane of sinus
Dura mater lining
pituitary fossa
Third nerve
Fourth nerve
First division of fifth nerve
Sixth nerve
Fig. 209–Showing the relative position of the structures in the right cavernous sinus,
viewed from behind. (After Gray.)
- .
Fig. 210.-Nerves of the head (from Arnold) seen from the side: a, Needle directed
along orbital route (Matas) into foramen rotundum; b, Härtel route to gasserian ganglion.
(Härtel.)





THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 545
Whatever the real basis of this relation may be in the individual
case, in practice both amount to the same thing; namely, that we may
not seek the puncture point in an exactly designated place, for ex-
ample, at the height of a certain molar tooth, but that the puncture
point varies within certain limits. We may not expect that we may
penetrate forthwith into the skull by any one puncture point selected
and reach our mark, but we must frequently make up our minds to
repeated puncture. This changes the puncture point until it has
reached the right axis, and now without resistance attains the cranial
º
Fig. 211.-Right pterygopalatine fossa, foramen rotundum and superior orbital fissure
seen from behind. Needle a is passed from the pterygopalatine fossa out of the foramen
rotundum. Needle b is pushed in a steeper direction through the inferior orbital fissure
and impinges within the superior fissure. (Härtel.)
cavity, a situation that we have indicated above by the expression
‘concentric puncture.”
“We have now examined the relation of the axis of the trigeminus
to the upper jaw in different skulls, and designate as the ‘middle part'
an axis which strikes the upper alveolar margin at the height of the
middle molar tooth (Fig. 202, a). ‘Steep' means (c) cutting point of
the axis with the posterior margin of the alveolar process, over steep'
(e) still farther back; level' (b) means cutting point under the process
of the malar bone at the height of the first molar tooth, over level’
(d) farther in front of it. The values found are entered in Table II,

35
546 LOCAL ANESTHESIA
No. 7. It follows from this that the ‘middle part axis is the most
frequent, and that in 90 per cent. of skulls the axis cuts the upper alveo-
lar margin in the region of the three upper molar teeth (Fig. 203, b, a, c).
frontal ºr of superf.
temporal art. x
_*peratis Frontails
Zº prºcularis orull
, temporal middle fem-
pterygold *:::::::::: º: poral vein
* may ſº _ -
-
rena-
pterus
- auriculo-femporal nerve
parietal br. of #:// /
tempºral a
supraorbital nerve
middle tempo-
ral vein M zygomatic bonex
middle fem- ...frontal nerve
poral art
auricula-fem- supratrochlear nerve
poral nerve \ forsal art. ºf nose
+
Z - angular art.
* …infratrochlear nerve
º Awarutal memºre
Art, marillary art.
* ſºlatanºstomotic
-- e
external
auditory
meaſus
n
_ext, nasal br.
ofant, ethm.
nerve
superf tem:
poral vein 2
***
affariatnerve -->
nerves to ext,’
- 2^ - - -
facial nerve’ - a - - - -
superf. º - a. - -
temp. arſ - - - -
º º - - - - -
- - - - - -
ſ . - -- - - - - * nerve
- r- - - Nº - Burrinator
stro- - - | - - - - -
mastoid art. A ---
-
posterior."
auricular art." /
A
orripital art.”
int, maxillary art.
sphenomandibular nº
external carotidarſ.
post facial veiß
Masseter’.
inf arreotar art.
lingual nerv
-- burrinator
art.
Sphincter"oris
inf aſveolar nerveſ
internal carotid are:
º - - -
º - - *art. facial vein
^ſ .
a -
y º - | - mental art.
external carotid arº.
Pigastricus (post, belly) # / 7.
externa maxillary art. / : Jugur, wer
- *
-
mental nerve
ar .
… - t
f - - -
*yoideus aſ:, ... connº º,..." . A Digastricus (ant, belly
g- Jacial * Inf, submeritan art
*:::: * + ...; x denta -
- ; ź. ºt plexus
mental wei fºrward -
errº ... larvart. X
Fig. 212.-The nerves and vessels of the face (fourth layer, the deep facial veins).
The zygomatic arch has been removed, the temporalis with the mandibular coronoid pro-
cess reflected upward, the mandibular neck excised, the external ear cut off, and the entire
mandibular canal opened up. *=Anastomosis between supratrochlear and infratro-
chlear nerves. ** = Branches of buccinator nerve passing to mucous membrane of the
cheek. -- = Mylohyoid nerve. -- on the vein = divided communication with ex-
ternal jugular vein. (Sobotta and McMurrich.)
We will, consequently, accept as a standard puncture point that op-
posite the second upper molar tooth (of course, outside on the cheek),
and if we do not come to the mark here we will vary the point on a
line parallel to the alveolar margin, reaching back to the ascending



























































THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 547
Fig. 213-Normal course of the internal maxillary artery on the outer side of the ext.
pterygoid muscle: I, Coronoid process; 2, temporal muscle; 3, deep ant. branch temp. art.;
4, infra-orbital artery; 5, post. sup. alveolar art.; 6, buccinator art. and nerve; 7, buccinator
muscle; 8, superficial temp. art.; 9, internal maxillary art.; Io, masseter muscle; 11, in-
ferior alveolar art. and nerve; 12, lingual nerve; 13, int. pterygoid muscle; 14, ext, ptery-
goid muscle. (After Poirier.)
Fig. 214.—Atypical course of the internal maxillary on the inner side of the external
pterygoid muscle: 1, Temporal muscle and coronoid process; 2, deep ant temporal artery;
3, infra-orbital artery; 4, post. sup. alveolar artery; 5, buccinator muscle; 6, buccinator
artery; 7, deep post temporal artery; 8, internal maxillary artery; 9, masseter; Io, inf.
alveolar artery and nerve; 11, lingual nerve; 12, int. pterygoid muscle; 13, ext, pterygoid
muscle. (After Poirier.)
branch of the lower jaw and forward into the region of the upper pre-
molar teeth (Fig. 204).


548 LOCAL ANESTHESIA
“Now that we have established a bone-way for the foramen ovale,
we must consider the relations of the Soft parts which our cannula
has to pass through from the cheek to the ganglion Gasseri.
“We had chosen our puncture point in the lateral region of the
cheek, opposite the alveolar margin of the second upper molar tooth.
The point of the cannula penetrates the skin and finds itself in Bichat’s
fat of the cheek. The finger, placed in the mouth of the patient, feels
the needle from the mucous membrane, and accompanies the advanc-
ing point of the same through the first strait between the margin of
the lower jaw and the tuber maxillare. The finger maintains the
b C
Fig. 215.-External lamina pterygoid process. Pterygopalatine fossa and maxillary
tubercle. Right side of skull seen from the side: a, Wide fossa with spinous tubercle (x);
b, medium wide; C–e, narrow fossa; d, anterior pterygoid spine (y); e, spinous tubercle (x),
and anterior pterygoid spine (y). (Härtel.) -
integrity of the mucous membrane of the vestibulum oris, this being
accomplished by a curved motion of the needle around the buccinator
muscle. The needle, therefore, goes between (medially) the buccinator
muscle on the one side, and the masseter muscle, lower jaw, with pro-
cessus coronoideus and temporal muscle (laterally) on the other
side, through into the fossa infratemporalis, and now endeavors by
perforation of the pterygoideus muscle externus, which fills the entire
fossa, to reach the planum infratemporale, in connection with which,
as we have seen above, finger-feeling can be auxiliary only in a portion
of the cases. We need, therefore, other fixed points. Such a point is

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 549
the depth. Before we stick the needle in we mark with the sliding
catch a distance of 5 to 6 cm.; in case of forward curving of the cheek
by a tumor, stillmore. We are thereby always informed as to the depth
reached, and can thus protect ourselves from gross errors. In the
second place we must now consider a direction discernible on inspec-
tion of the whole skull, and we have been able by careful observation
and many examinations to establish as essential for the puncture of
the foramen ovale the following fixed points:
Fig. 216–Lateral route to foramen rotundum. (Braun.)
“(1) Viewed exactly from the front (for this determination of
direction one must, like the designer, see with one eye only, and possibly
with the aid of a second cannula held freely before one), the cannula
introduced into the ganglion points to the pupil of the eye on the
same side (Fig. 205). If we observe this rule, then we avoid deviat-
ing outwardly into the fossa temporalis, inwardly into the tube and
pharynx region.
“(2) On exact lateral inspection the cannula points to the tuber-

55o LOCAL ANESTHESIA
culum articulare of the zygomatic arch (Fig. 205), If we do not ob-
serve this rule, then it may happen that we come too far forward into
the fossa pterygopalatina, or too far back into the region of the fora-
men caroticum and of the foramen jugulare; the latter way, particu-
larly—namely, the introduction of the needle into the medial part
of the foramen jugulare instead of into the foramen ovale—we have
several times taken wrongly on the cadaver, and the cannula appeared
at the base of the skull, at the place of entry of the nervus vagus and
glossopharyngeus into the dura.
Fig. 217.-Lateral injection of second division of fifth nerve in pterygopalatine fossa.
(Härtel.)
“Viewed from below (with the skull inverted), the angle of the
needle is seen in Fig. 219. Figure 220 is a sagittal section of the
skull, and shows the axis of the needle seen from within. Figure 221
is a skiagraph of the needle transfixing the ganglion. In Fig. 222 is
seen the angle and point of crossing within the skull of the axes of the
needle if continued backward in bilateral puncture.
“The observance of the rule given above for the direction, as well as
naturally the bone-feeling on the planum infratemporale, protects us
certainly from this error. The pterygoid muscle is perforated near

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 55I
its origin on the pterygoid process and tuber maxillare; often the can-
nula goes through between the two heads of origin.
“Before we conduct the point of the needle from the fossa infra-
temporalis into the foramen ovale, we take the precaution of slipping
back the sliding catch of the cannula 1% cm. from the skin-puncture
place, in order thus to be aware of the depth of the further advance.”
A summary of the essential points in making the Härtel puncture
is given by Härtel as follows:
“(a) Puncture in the cheek at the height of the alveolar margin of
the second upper molar tooth, establishing first on the cheek a wide
Fig. 218–Pterygopalatine fossa and contents, showing the S form of the maxillary
nerve and the position of the terminal branches of the internal maxillary artery beneath the
nerve: 1, Zygomatic nerve; 2, infra-orbital artery; 3, int. maxillary artery; 4, mandibular
nerve; 5, maxillary nerve; 6, sphenopalatine ganglion; 7, ophthalmic nerve; 8, int. carotid
art.; 9, gasserian ganglion. (After Testut and Jacob.)
area of cutaneous anesthesia, which allows a variation of the puncture
point toward the front or back according to the principle of the con-
centric puncture. - -
“(b) The cannula for puncture must be oS mm. thin, Io cm. long,
and be provided with a flatly ground point. Before the puncture with
the puncture-cannula, the anticipated puncture depth to the planum
infratemporale (5 to 6 cm.) is marked on the same with the help of an
aseptic ruler by the sliding catch used on the cannula.

552 LOCAL ANESTHESIA
“(c) Introduction of the cannula, accompanied by finger-feeling
between the anterior margin of the ascending branch of the lower jaw
and the tuber maxillare around the buccinator muscle to the fossa
infratemporalis.
Fig. 219.-Shows direction of needle in transfixing gasserian ganglion by Härtel
route, viewed from base of skull. (Original illustration from collection of Prof. Matas.)
“(d) Determination of the direction—seen from the front the can-
nula points exactly to the pupil of the eye on the same side; seen from
the side, to the tuberculum articulare of the zygomatic arch.
Fig. 220.-Shows axis of needle in transfixing gasserian ganglion by Härtel route,
seen from within on sagittal section of skull. (Original illustration from collection of
Prof. Matas.)
“(e) The puncture of the foramen ovale takes place under continu-
ing feeling with the hard and smooth surface of the planum infra-
temporale from the anterior exterior long side of the foramen.


THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 553
“(f) After the foramen ovale is reached (relaxing of resistance,
radiating pain in the area of distribution of the third branch) the slid-
ing catch is shoved back 14 cm. from the puncture point of the skin,
and the cannula is introduced into the foramen ovale until pain is
experienced also in the area of distribution of the second branch.
“(g) Attachment of the syringe containing 2 c.c. slow injection
of the Solution, which must not exceed I c.c.
“(h) Immediate testing of the anesthesia.”
Within the middle fossa of the skull (Figs. 207, 208) the following
points are of interest: In front is seen the foramen lacerum anterius,
and immediately below this the foramen rotundum, with its axis di-
rected downward, forward, and outward into the sphenomaxillary
fossa. Posterior and external to the foramen rotundum is seen the
foramen ovale.
The foramen spinosum lies slightly external and behind the plane
of the foramen ovale and its artery (middle meningeal). As it
leaves the foramen it curves outward hugging the bone; this vessel
also is out of danger from the needle being advanced too far within
the skull.
At the apex of the petrous portion of the temporal bone, where
this bone is received into the angular interval, between the basilar
process of the occipital and the posterior border of the great wing of
the sphenoid, is seen the opening of the internal carotid artery and
foramen lacerum medium.
The cavernous sinus courses along the inner margin of the middle
fossa, with the internal carotid artery lying along its inner wall, both
internal and above the foramen ovale. The position of the vessel at
this point and its relation to the sinus and orbital nerves are shown in
Fig. 209. Above and behind the foramen ovale is seen the depression
for the gasserian ganglion. Above and behind this depression on the
superior margin of the petrous portion of the temporal bone is seen
the groove for the superior petrosal sinus.
The gasserian ganglion, slightly crescentic in shape, with its Con-
vexity forward, lies within the above depression, its upper Surface in-
timately adherent to the dura mater. Beneath it pass its motor root
and large superficial petrosal nerve; the large or sensory root runs
forward toward the ganglion from its origin in the pons. Through an
oval opening in the dura mater (the cavum Meckeli), and guarding
this opening posteriorly into the cysterna pontis of the Subarachnoid
space, is a reticulated membrane—the porus trigeminus.
This communication of the ganglion with Subarachnoid space
554 LOCAL ANESTHESIA
through the cavum Meckeli is of considerable consequence in the
deep injections of the ganglion, as spoken of later. The anatomy of
these parts, as discussed by Härtel, is as follows:
“Let us now consider the anatomy of the cavum Meckeli and of the
ganglion Gasseri (Figs. 168, 208, 210). The trunk of the nervus tri-
geminus rises in the region of the posterior cranial fossa out of the pons,
next passes through the wide cavity of the cysterna pontis, which is
filled with cerebrospinal fluid, and then enters between the sinus
petrosus superior and the Superior margin of the petrous portion
of the temporal bone through a wide, oval gate of the dura mater
(the porus trigemini), into the cavum Meckeli belonging to the middle
cranial fossa. It has less the form of a compact nerve-trunk than that
of a bundle of nerve-fibers, lying loosely together, which, as is well
known, are covered only with the pia mater. In the cavum Meckeli
the nerve forms the area triangularis, and radiates into the ganglion
semilunare, which extends itself toward the front along the root of the
great wing of the sphenoid, and sends off the three trunks of the
trigeminus through the fissura orbitalis Superior, the foramen rotun-
dum, and ovale.
“The relation of the ganglion to the walls of the cavum Meckeli,
which is formed out of a fold of the dura mater, is as follows: With
the substratum, the dural membrane, that serves at the same time as
the cranial periosteum, the ganglion is but loosely connected by means
of loose connective tissue; with the Superior dural wall on the con-
trary it is intimately united. The three trunks of the trigeminus leave
the ganglion Gasseri as compact nerve-trunks closely adherent to the
dura. Of course, the motor portion of the trigeminus does not par-
ticipate in the formation of the ganglion. It takes its origin as the
portio minor before the sensory portio major; it passes then on the in-
ferior side of the ganglion, and joins itself to the third branch.
“From this situation of the nerves arises the fact that the resist-
ance to a liquid injected with a syringe under pressure is least on the
under side of the ganglion and at the place of the entrance of the
main trunk of the trigeminus into the cavum Meckeli. Hence, there
exists the possibility that the injected fluid may soak through the porous
trigemini into the cysterna pontis. On Sudden injection of staining
solution in the cadaver this may be observed, and outside of the
ganglion may be produced a staining of all the arachnoid spaces of
the base of the brain. It appears to me that it may very well be
possible that the condition of sleep observed clinically by us and by
Heymann, in connection with an injection of a copious quantity of
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 555
Solution into the ganglion Gasseri, is to be attributed to this arachnoid
infiltration.
“Of greatest importance for us, further, is the situation of the
medial wall of the cavum Meckeli, which forms the dividing wall of the
Same from the sinus cavernosus. This medial wall is a thin, translucent,
dural membrane. The first branch of the trigeminus, immediately
after its emergence from the ganglion, turns into this dural membrane
with a geniculate bend, and fuses with it so intimately that a macro-
Scopic Separation of the sinus wall from the nerve is not possible. If
in anatomic books (Fig. 209) the nervus trigeminus I, oculomotorius,
and abducens are represented as passing “in the lateral wall’ of the
sinus, then this statement must be supplemented thus: that the rela-
tion of the two nerves of the muscles of the eye to the lateral wall is
a much looser one than that of the first branch of the trigeminus.
If one injects with a syringe into the ganglion Gasseri small quantities
of Solutions that are diffused with difficulty, such as ink or tincture
of iodin, then one obtains a beautiful infiltration of the ganglion and
of the chief trunk of the trigeminus, while the sinus cavernosus and
the cisternae of the arachnoid membrane remain free; on the other
hand, aqueous solution of methylene-blue is diffused into the sinus as
well as into the cisternae. On the relation of the sinus cavernosus to
the cavum Meckeli, just described, depends the appearance observed
by us at first on too sudden injection of quantities of solution exceeding
I c.c.; that is, an overlapping of the paralyzing effect of the novocain
on the nerves of the muscles of the eye, which manifested itself either
in transient dilation of the pupil concerned or in a likewise transient
paralysis of the abducens.”
The distance between the various points of interest within the skull,
as measured by Härtel, are of interest.
From the superior margin of the pyramid of the petrous portion
of the temporal bone to the posterior-inferior margin of the foramen
ovale he gives a minimum of 14 mm., maximum of 23 mm., with an
average of 19 mm. (See Table II, No. 6.) -
The minimum of 1.4 cm. is the safe maximum depth to penetrate
within the foramen; if a greater depth is reached, there is danger of
puncturing the membranes and entering the cisterna pontis. This
actually happened to Härtel, with the escape of cerebrospinal fluid;
besides, there is danger of wounding the superior petrosal sinus or of
injecting the solution beyond into the posterior fossa of the skull.
The shape and size of the foramen ovale vary considerably in dif-
ferent skulls, and even on the two sides of the same skull, to Such an
556 LOCAL ANESTHESIA
extent that a study of a large number of skulls is necessary to draw
any positive conclusion. A composite of the whole, giving the aver-
age condition and variations from this average, must necessarily be
less in a large number of cases than measurements or studies made
upon any single skull.
The same may be said about the relative position of the foramen
in relation to the surrounding parts; this variation of position, how-
ever, is less than that of the size and shape of the foramen.
The sphenomaxillary fossa is a small triangular space, situated
beneath the apex of the orbit at the angle of junction of the spheno-
maxillary and pterygomaxillary fissures. Its posterior wall is formed
by the base of the pterygoid process and body of the sphenoid, which
slightly overhang it in this position; its inner wall is formed by the
vertical plate of the palate bone, which slightly overhangs it on the
inner side; in front is the middle portion of the tuber maxillare.
Externally, it opens into the temporal and zygomatic fossa through
the pterygomaxillary fissure.
Above the roof is partially deficient, where it communicates with
the apex of the orbit beneath the sphenoid fissure. -
Five foramina open within this fossa; on the posterior wall is the
foramen rotundum; above, below, and internal to this the vidian, and
still more inferiorly and internally, the pterygopalatine; on the inner
wall is the Sphenopalatine foramen, by which the fossa communicates
with the nasal cavity. Below is the Superior openings of the posterior
palatine canal. This fossa contains, besides the superior maxillary
nerve and its branches, Meckel’s ganglion and the termination of the
internal maxillary artery. It will be seen, from a study of the above
and the use of a needle on the skull, that the transverse puncture
made from below the zygomatic arch may, if the point of the needle
is directed too high and advanced too far, enter the apex of the orbit
and transfix the structures passing through the sphenoid fissure (Fig.
2II), or may, if advanced sufficiently far, enter the orbital foramen;
and, if directed more horizontally and advanced too far, may enter
the nasal fossa through the sphenopalatine canal.
This last fossa may even be entered from above the zygoma, but
from this angle it would be impossible to enter the orbit. For this
reason Some Operators prefer the transverse route above the zygoma
instead of below it.
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 557
INTERNAL MAXILLARY ARTERY (Fig. 212)
The larger of the two terminal branches of the external carotid
is given off at about the level of the lower extermity of the lobule of
the ear, at its origin embedded within the substance of the parotid
gland. It first runs inward, at right angles to its point of origin, to
the inner side of the neck of the condyle of the lower jaw, in this its
maxillary portion lying between the ramus of the jaw and the internal
lateral ligament. As it passes opposite the sigmoid notch it lies usu-
ally a little above its lower border, but usually about 1 cm. below the
inferior border of the zygoma. In some few cases the artery may lie
below the tendon of the external pterygoid, and, in crossing inward
from this position, may be in danger of being wounded (Figs. 213, 214)
when approaching the foramen ovale from below and in front, as in
the Härtel route, or slightly more below the level of the lower border of
the zygomatic process. Consequently, a needle entered at the lower
border of the zygoma should be well above it, but if passed through the
lower part of the sigmoid notch may come in contact with it.
As the artery passes forward and inward it lies parallel to the
auriculotemporal nerve, above and in front of the inferior dental
and along the lower border of the external pterygoid muscle. It then
runs obliquely forward and upward, over the surface of this muscle
(pterygoid portion). In its third or sphenomaxillary portion the
artery runs transversely in a tortuous manner, and, while somewhat
variable in its course, always lies below the superior maxillary nerve
in the sphenomaxillary fossa, where it lies in close relation to Meckel's
ganglion. --
The only branch of this vessel of particular interest to us is the
middle meningeal, which is given off opposite the sigmoid notch, and
ascends almost vertically to the foramen spinosum in its course. It
usually lies behind the transverse tract of the needle in a lateral punc-
ture, but may occasionally lie more anteriorly. A small branch, the
small meningeal, passes up through the foramen ovale, but this, with
the internal maxillary vein, lies below and in front of the artery.
Other branches are either of small size or are situated outside of
the course of the needle, and are of no particular concern to us here.
The best protection against the injury of a vessel here, as well as
elsewhere, in making deep punctures is in the proper Selection of the
needle or cannula, combined with its skilful and careful use.
By the use of a small-calibered needle with flat point, and not a
course needle with sharp, long point with cutting edges, the likeli-
hood of a serious injury to a vessel is practically negligible, and amounts
558 LOCAL ANESTHESIA
at most in cases in which it does occur to a small hematoma or slight
ecchymosis at the point of puncture, which is probably from injury of
a vein, the arteries having tougher walls and being more easily dis-
placed.
On the lateral aspect of the skull in the transverse methods of
approach to the foramen rotundum and Sphenomaxillary fossa two
routes are available: one above, the other below, the zygoma.
The upper route rarely reaches the foramen rotundum, but enters
the sphenomaxillary fossa just below the foramen. The best method
of utilizing this route is to enter the needle high up on the cheek in
the notch formed by the union of the zygomatic and frontal processes
of the malar bone. From this point the needle is advanced transversely
inward, when it impinges against the great wing of the sphenoid just
above the pterygoid ridge. The point of the needle is now success-
ively lowered until it slips beneath this ridge and enters the fossa.
It is now advanced about 1 cm. further, and the injection made at a
depth of about 4% to 5 cm. from the surface.
In entering this fossa, if the point of the needle is advanced too far
forward it strikes upon the rough upper projection of the tuber maxil-
lare, along which it must feel its way backward; if advanced too far
backward it meets the external pterygoid plate near its base, and must
be successively advanced forward until it slips over the sharp laterally
projecting edge of this bone into the fossa beyond (Fig. 215).
If advanced too far within the fossa, it is possible to pass beyond
and enter the nasal cavity through the sphenopalatine foramen, which
lies about on a level with this line of puncture.
In entering the fossa from below the zygoma (Fig. 216) there are
certain dangers to be avoided. The point of puncture lies below the
notch on the malar (formed by the zygomatic and frontal processes)
and about on a lateral plane with the posterior surface of the tuber
maxillare. From this point the needle is advanced inward with an
upward inclination, passing between the tuber maxillare in front and
the pterygoid process behind, through the pterygomaxillary fissure
into the fossa just beyond, to a depth not to exceed 4% to 5 cm.; the
upward inclination of the needle is such that at this depth the point
should be about 1% to 2 cm. above the point of puncture.
If the needle is advanced too far inward, and particularly if the
point of entrance be slightly below the edge of the zygoma and the
angle of the needle be too high, it is possible to pass beyond the sphen-
maxillary fossa and transfix the structures, passing through the supe-
rior orbital fissure or even enter the orbital foramen.
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 559
As the axis of the foramen rotundum is at an angle with this and
other transverse methods of puncture, it is only possible in about one-
third of the cases to enter this opening; however, the fossa just in front
of the forearm is readily reached and the nerve often transfixed at
this point, or the Solution deposited in direct contact with it.
A method erroneously attributed to Matas, while used at about the
same time by him, is probably to be credited to Schlösser. This method
has its puncture point slightly below and behind the malar prominence.
From this point the needle, directed backward, upward, and inward,
feels its way along the posterior surface of the tuber maxillare until
it slips beyond its posterior projection through the pterygomaxillary
fissure into the Sphenomaxillary fossa at a depth of about 4% to 5 cm.
from the surface. -
In discussing this fossa, the anatomic variations in its bony sur-
roundings, and the methods of puncture Härtel states the following.
(In this discussion of the various methods of approach the Matas
route is referred to as a transverse route beneath the zygoma. This
route, while used by Prof. Matas probably independently and about
the same time (1898) should, I believe, be credited to Schlösser. The
original Matas route is the orbital puncture through the sphenomaxil-
lary fissure.)
“Let us consider next the lateral entrance (Fig. 215). This has
a sickle shape, which in its superior end continues into the inferior
orbital fissure. The posterior margin of this sickle consists of a
bone corner which is formed by the anterior boundary of the lamina
externa of the pterygoid process, and above tapers into a ridge which
separates the planum infratemporale from the planum orbitale of the
great wing of the sphenoid bone, and is furnished with a process called
tuberculum spinosum (Fig. 215, a, 3). The anterior concave margin
of the sickle is formed by the opposite surface of the tuber maxillare.
“According to the greater or less pneumatization of the antrum of
Highmore, the tuber maxillare juts out behind more or less, so that the
sickle form may vary from a small fissure (type en cornue,' Fig. 215,
c—e) to a half-circle (‘type ovalaire,’ Chipault, Fig. 215, a-b). The
transverse diameter is correspondingly variable. It amounts (Table
II, No. 9) in the minimum to 3 mm.; in the maximum, to II mm.,
and on the average, to 5.4 mm. A ‘narrow fossa’ with a width under
5 mm. we find in about 40 per cent. of the cases.
“Besides, there are the varieties of the posterior margin, which are
dependent on the development of the masseters. The under part of
the same, which belongs to the pterygoid process and almost always
560 LOCAL ANESTHESIA
presents a very characteristic corner, which we wish to call Grenzleiste
(marginal ridge), projects in special cases sharply and like a knife
opposite the entrance of the fossa, and may bear a prong, which is
called spina pterygoidea (Fig. 215, d, e, y). Just so, the Superior part
belonging to the great wing of the Sphenoid bone may be either Smooth
or form an elevation, Soon becoming pyramidal in shape or ridge-like,
or running out into a point, the tuberculum spinosum already men-
tioned. Between these two spines a ligament may develop similar
to the ligamentum pterygospinosum (Poirier), which has been described.
The different types of the entrance of the fossa pterygopalatina are
placed together in Fig. 215 and in Table II, No. Io. The relations
of the entrance to the fossa are of importance for the ways of access of
Matas (1) and Offerhaus (3). As far as the latter way is concerned,
it is, in general, not practicable if the point of puncture above the zygo-
matic arch is chosen, for, according to Table II, No. II, the needle in-
troduced in this way only in a small portion of the cases (12 per cent.)
reaches the superior part of the fossa which receives the nervus maxil-
laris; but also for the Matas-Braun way unfavorable varieties of the
entrance present great difficulties.
“If we now consider the interior of the fossa, this is also subject to
great changes. Of most importance to us is the posterior wall with
the surroundings of the foramen rotundum, for a puncture of the
nervus maxillaris can be successful in the whole region only if it reaches
it shortly after its exit from the foramen rotundum, before it has given
off its branches. This posterior wall can be likewise strongly changed
only through the pneumatization of the bones forming it. Sometimes
one finds the entire fossa walled up transversely or lengthwise with
pneumatized walls, which belong to the sphenoid bone or else to the
palatine bone. -
“If we now next test the bony skull as to the possibility of punctur-
ing the foramen rotundum directly by the Matas way (should be
Schlösser—Author), then it is shown that only in 33 per cent. of the
cases (Table II, No. 12) does the possibility exist of penetrating with
the point of the cannula more or less deeply into the foramen, a
possibility which by the orbital way (original Matas route—Author)
—incidentally noted—is much greater (89 per cent.). Consequently,
with the lateral puncture we cannot practically reckon on a direct
injection of the foramen rotundum, but must content ourselves with
washing the nervus maxillaris in the fossa.
“If we now seek fixed points for a successful puncture of the fossa
Sphenomaxillary, then here also the method of concentric puncture is of
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 561
importance: for, on the one hand, we must shift the puncture point
as much as possible to the front, in order to carry the needle to the
posterior wall of the fossa; on the other hand, it may happen that, with
a puncture point shifted too far to the front, the tuber maxillare ob-
structs the approach. Most frequently the puncture point by which
it is possible to reach the exit of the foramen rotundum lies under the
sutura zygomatico-malar, which is marked by a prominence, and in
the living subject is usually palpable or somewhat behind this same
suture. (See Table II, No. 13.)
-
Fig. 221.-Skiagraph of needle transfixing gasserian ganglion by Härtel route; shows
axis of needle in relation to teeth and bony parts of face and skull. Injected vessels are
also seen. (Original illustration from collection of Prof. Matas.)
“Gliding backward on the tuber maxillare we come to the entrance
of the fossa, and guide ourselves now to the opposite posterior wall,
while we seek to come into the turning-corner of ridges bordering this
wall, since with a higher puncture (Fig. 211) we are in danger of com-
ing into the orbit, with a deeper one into the nasal cavity. Further,
we must reflect that after passing the entrance we dare not go too
deep-1 cm. at the most, which we can control by our sliding catch.
The total depth amounts to 45 to 57 mm., on the average 50 mm. (See
Table II, No. 14.)
“Favorable for the injection into the fossa is the circumstance that
it is filled with loose masses of fat, which permit a good diffusion of

36
562 LOCAL ANESTHESIA
the injected solution into the vicinity. The nervus maxillaris (Fig.
218) itself lies in the uppermost part of the fossa sphenomaxillary, and
is fixed to its roof by connective tissue. In its course it takes an S-
form, which in a sagittal direction comes out of the foramen rotundum;
it bends laterally, in order to arrive at the sulcus infra-orbitalis of the
upper jaw, when it takes the sagittal direction again. The orbital
puncture follows the direction of this nerve-trunk itself, which in its
manner presents a similar axial puncture.”
Braun Method.—This is an effective and simple means of reach-
ing the trunk of the third division at its exit from the skull, and fairly
Fig. 222.-Angle and point of crossing within the skull of the axes of the needle in the
Härtel route, if continued backward in a bilateral puncture. (Original illustration from
collection of Prof. Matas.)
as accurate as the Offerhaus, Härtel, or any other route for reaching
the trunk of the nerve and much easier executed.
The needle is entered at about the midpoint of the zygoma on
its undersurface, and directed transversely inward until it strikes
upon the external plate of the pterygoid process near its base (Fig.
223). It will be seen, from a reference to the position of these parts,
that the foramen ovale lies directly back of the base of this plate and
on the same anteroposterior plane, consequently the depth to the
external plate at its base is the depth to the foramen ovale, but on a
slightly posterior plane, about 1 cm. Having now determined the
depth from the surface necessary to penetrate, this is marked on the

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 563
needle, which is partially withdrawn, and the point redirected slightly
backward, in which direction it is advanced to the determined depth.
When the nerve is reached this is recognized by the usual paresthesia
along its branches.
The method of Offerhaus is a decidedlyingenious and valuable acqui-
sition. To him is due the credit of attempting the first time to locate
the relative positions of the foramina ovale and rotundum by ana-
tomic measurements made on the base of the skull. This method aims
W. - - - - Foramen
º ovale
Fig. 223.-Lateral routes of injection for foramen ovale: I, Offerhaus; 2, Braun. (Braun.)
to make the injections immediately beneath the foramina, reaching
the nerves just as they leave the openings, at their approximately de-
termined depth from the surface. This method, when applied with
some judgment, making allowances for anatomic variations in individ-
ual cases by slightly manipulating the point of needle until it comes in
contact with the nerve, which is recognized by the characteristic
paresthesia along its branches, will be found to be a highly useful and
valuable procedure.


564 LOCAL ANESTHESIA
In a study of 5o skulls Offerhaus found that the distance between
the foramen ovale is approximately the distance from the two outer
surfaces of the alveolar processes, opposite or just behind the last
molar tooth, at the point where the processus pyramidalis ossis pala-
tini joins the maxillary bones; this, then, is the distantia interalveo-
laris externa (D A. E.), and equals the distantia foramina ovale
(D. F. O.) (Fig. 224).
Fig. 224.—Offerhaus method for measuring base of skull to determine distance of foramen
ovale from articular tubercle. (Braun.)
The distance between the foramina rotundum is the same as the
distance between the alveolar processes of the maxilla on the inner
side, behind or along the side of the last molar.
Distantia interalveolaris interna (D. A. I.).
The axis in which lie the foramina rotundum reaches the surface
at the upper border of the zygomas at the point where the temporal

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 565
portion merges with the molar; this is about the midpoint of the zygo-
matic arch, the linea interzygomatica.
The foramina rotunda lie about 2 to 4 mm. just above and behind
this line. The axis in which lie the foramina ovale passes over the
eminentia articularis and through the articular tubercles; occasionally
the foramen lies 2 or 3 mm. back of this line, but as the axis of the
nerve is downward and forward it usually passes through this axis.
While the relative position and distances between these parts may vary
slightly in different skulls, as well as on the two sides of the same skull,
these measurements may be relied on as approximately correct, varying
only within a few millimeters.
Fig. 225–Method of using Offerhaus calipers. (Braun.)
In the clinical application of this method the distantiainteralveolaris
externa is measured with an ordinary pair of calipers or a compass; this
is usually found to be about 5 cm., and equals (D. F. O.) distantia
foramina ovalis; the distantia intertubercularis is next determined
by specially constructed calipers (Fig. 225), though any instrument
adapted to this purpose will do. On the Offerhaus calipers there is
a movable part, which is attached to the point and projects outward
to indicate the direct angle of puncture. These are usually placed
on after the distance has been determined, which is shown by a scale
to which the arms of the caliper are attached and along which they
move. As the articular tubercles are usually easily felt, just in

566 LOCAL ANESTHESIA
front of the temporomaxillary articulation at the root of the zygoma.
this measurement is very simply made. In fleshy individuals a small
allowance, about I cm., may have to be allowed for soft parts. -
This distance is usually about 14 cm. We then subtract from this
the distance between the foramina ovale, 5 cm., previously determined
by measurement, between the alveolar processes, and divide by two.
* 5 -
the needle must travel to reach the nerve-trunk.
Occasionally, the ossification of the ligament pterygospinosum pre-
sents a bony barrier to the passage of the needle along the linea inter-
tubercularis. When this exists there is usually an opening through
this plate near the base of the skull, just to the side of the foramen ovale;
this is best found by feeling with the needle along the smooth surface
of the planum infratemporalis toward the foramen, and the opening
through the obstructing plate is usually entered without much diffi-
culty.
For injecting the second division the linea interzygomatic is deter-
mined by measuring with the large calipers the distance between the
midpoints on the two zygomatic arches; from this is subtracted the
distance between the inner surfaces of the alveolar processes at the
last molar tooth, and this figure divided by two in the same way as for
the preceding method.
This then gives us the depth to which the needle must travel
to reach the second division of the fifth. Offerhaus advises that
the needle be entered above the zygomatic arch for reaching the
trunk of this nerve, but where it is desired to make the injection at
the foramen rotundum the needle is entered below the zygoma, di-
rected slightly upward. A very large coronoid process may check the
passage of the needle here, in which case, if the mouth is opened wide,
this descends out of the way. -
The same difficulties may be encountered here in passing the needle
within the sphenomaxillary fossa, as already mentioned in discussing
those regions, and the same rule should be applied here to overcome
these difficulties. Occasionally, this method may have to be abandoned
in cases where the sphenomaxillary fissure is reduced to a mere slip,
too narrow for the passage of the needle by the too close approach of
the tuber maxillare to the pterygoid process. In this case the Matas
route should then be tried.
Offerhaus recommended that 2 c.c. of from o.5o to o.75 per cent.
cocain and adrenalin be used in making either injection. It would,
= 4.5 cm., the distance along the linea intertubercularis which
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 567
however, seem best, in the writer's opinion, to use stronger solutions
of novocain and adrenalin (2 c.c. of a 2 per cent. solution), as is sug-
gested by most operators making these injections.
Offerhaus states that complete analgesia usually occurs in about
fifteen minutes and lasts about one hour. This time could prob-
ably be lengthened by the use of stronger solutions, as suggested.
The utilization of these methods of measurement, as taught us
by Offerhaus, may be applied to any other route of puncture applied
Fig. 226.-Novocain anesthesia of the Fig. 227.-Anesthesia following alco-
right gasserian ganglion, tested immedi- hol injection in the left ganglion, tested
ately after injection. (Hartel.) immediately following injection. (Härtel.)
to the same region, and should serve as a valuable guide in determin-
ing the depth of penetration.
Härtel has done considerable work in clearing up certain inaccu-
racies and uncertainties which existed regarding the areas of distribu-
tion of the different branches of the fifth nerve. He shows these areas
as taught in most of our text-books, and in Figs. 226-230 shows a
number of anesthetized surfaces outlined immediately after unilateral
ganglion injections. The tests were made with needles on patients
sufficiently intelligent to make comparatively accurate observations;
certain inaccuracies are, however, bound to occur, as marginal areas

568 LOCAL ANESTHESIA
show diminished sensibility and adjacent surfaces are overlapped by
the opposite nerve in a zigzag manner.
In the median line of the face the limits between the two sides were
rather sharply defined, as variations were not so numerous as had pre-
viously been supposed; still this overlapping may take place suffi-
ciently in spots to make it always advisable to anesthetize both sides
in operations approaching the median line.
On the skull, in the midline, the area of anesthesia extended well
up toward the vertex capitis, but laterally in the region of the auricle
Fig. 228.-Novocain anesthesia of Fig. 229.-Novocain anesthesia of
right gasserian ganglion, tested immedi- right gasserian ganglion, tested immedi-
ately after the injection. (Härtel.) ately after the injection. (Härtel.)
some variations were met with. He calls attention to this extended
area of anesthesia as offering favorable opportunities by this method
for trephining, etc., upon the sinciput.
“In the face the area of distribution of the cervical nerves (nervus
auricularis magnus, cutaneous colli) projects from below laterally more
or less extensively into the trigeminus region, so that we never can
reckon on pure trigeminus anesthesia in the region of the auricle,
lateral temples, cheeks on the sides, the parotid gland, at the angle
of the jaw and chin, and hence must always prefer infiltration to
ganglion injection.

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 569
“Relative to the innervation of the face, observations which we
have made after alcohol injection as to the capacity for regeneration
of the sensibility are of interest. Figure 230 shows the area of diffu-
sion of the analgesia twelve days after the alcohol injection into the
ganglion Gasseri; Fig. 231, the same twenty-five days after. We
see clearly how, especially in the frontal regions of the margins, col-
lateral tracts of sensibility are developed. In the same category the
observation belongs that after ganglion injection the anesthesia died
out earliest in those regions whose nerves were treated earlier with
\
Fig. 230–Anesthesia twelve days after Fig. 231.-Same as Fig. 230, twenty-five
alcohol injection of right gasserian gan- days after injection. (Härtel.)
glion. (Härtel.)
peripheral alcohol injection. If we compare our areas of anesthesia
with the anesthesias found by Krause, after the extirpation of the
ganglion Gasseri, then we find that ours are more extended and
approach more closely to the statements of the anatomists. This is
attributable to the fact that our tests were undertaken immediately
after the injection, while Krause, for independent reasons, first
undertook the tests of sensibility eighteen days after the operation.
“2. Deep Sensibility.—By ganglion injection the collective bones
and soft parts of the face become anesthetic, as far as they belong to
the area of distribution of the trigeminus. If the operation ap-

57O LOCAL ANESTHESIA
proaches the median line, bilateral anesthesia is to be preferred. Re-
sections of the upper jaw, operations on the bones of the nose and
orbit, are thoroughly feasible under this anesthesia.
“The mucous membranes of the eye and nose are certainly without
feeling, as well as the conjunctiva and cornea. The corneal reflex
dies out, also the sneezing reflexes of the nasal mucous membranes,
but on the contrary the vomiting reflex of the pharynx does not.
The accessory cavities of the nose are likewise anesthetic. Radical
operations of empyemas of the antrum of Highmore are feasible
with unilateral ganglion anesthesia. For the ethmoid cavity double
anesthesia is always to be recommended (Fig. 193). Observations
concerning the sphenoid sinus and the hypophysis are not available.
“In the oral cavity complete
anesthesia of the teeth, the jaws,
and the hard palate are to be
reckoned on, but the soft palate
is not always entirely without
feeling. Likewise the anesthesia
of the tongue, at least in the
posterior part, is very uncertain
after double ganglion injection.
If we observe the diagram of the
sensibility of the tongue (Fig.
232), then we see that only the
anterior part belongs to the tri-
geminus, the lateral parts to the
gloSSpharyngeus, the base to the
* - . vagus. According to our experi-
Nez ments, the trigeminus region of
Fig. 232.-Sensory innervation of the the tongue is to be restricted still
tongue: I and 2, Vagus nerve (dotted); 3 and m0re. Perhaps Sensory fibers
5, glossopharyngeus (oblique lines); 4 and are received through the chorda
6, lingual nerve (horizontal lines). (After tympani, which communicate
Zander and Spalteholz.) y
with the facialis, thence to the
trigeminus, and are conveyed to the glossopharyngeus. Therefore,
for tongue operations conduction anesthesia in the lingula appears
to us to be more certain than at the base of the skull or in the foramen
ovale. Accordingly, for the operation for carcinoma of the tongue,
as we shall see later, ganglion anesthesia has little significance; here
with our earlier procedure we obtained the same, if not better, results.
“In the case of large operations in the nasopharynx, on the con-

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 57I
trary, I might not dispense with ganglion anesthesia on account of
the division of the second branch (compare Table I), yet here also,
as in all marginal areas, it is to be combined with copious infiltration.
“The area of the application of the conduction anesthesia of the
ganglion Gasseri is, therefore, as follows:
“(I) Operations on the anterior skull, the orbit, the malar bone,
the upper jaw, the nasal cavity, the oral cavity, and the pharynx,
sometimes combined with adrenalin infiltration for the purpose of the
production of bloodlessness and with novocain infiltration of the
uncertain marginal regions (region of the skin of the cervical nerves,
region of the glossopharyngeus), as well as the cocainizing of the
mucous membrane not in the area of distribution of the trigeminus.
“(2) Plastic operations on the face.
“(3) Operations on the branches of the trigeminus and on the
ganglion Gasseri. The so far favorable results of alcohol injection,
in cases of trigeminus neuralgia, make it altogether probable that the
operations on the trunks may be discontinued in the future, that the
extirpation of the ganglion Gasseri may still be necessary only in very
rare instances.
“The duration of the novocain anesthesia of the ganglion Gasseri
amounts on the average to one and one-half hours; this is true for the
Braun tablets dissolved in cold normal salt solution. Attempts to
boil up the solution once more with the addition of hydrochloric
acid resulted in a very transient anesthesia of short duration.”
In discussing the clinical application of his method, Härtel states
the following:
CONDUCTION ANESTHESIA AND INJECTION TREATMENT OF THE
GANGLION GASSERI
“The technic of the puncture of the ganglion Gasseri has been
exactly described in the first part of the work. The instrumentarium
consists of: (a) a nickel-plated steel cannula, Io cm. long, o.8 mm. thick,
furnished with a flatly ground point and a sliding catch; (b) a fine
needle for the skin-anesthesia; (c) a Record syringe, and (d) a metal
ruler by means of which the desired depth is fixed on the needle with
the sliding catch (Windler, Berlin) (Fig. 233).
“For the performing of the puncture the patient is laid down on
the operating-table, with the upper part of the trunk raised somewhat
and the head lifted up by a pillow. After disinfection of the cheek
with alcohol or tincture of iodin, the skin-anesthesia is produced, then
with the long needle, on which the anticipated depth of the planum
572 LOCAL ANESTHESIA
infratemporalis (5 to 6 cm.) is marked by the sliding catch, the punc-
ture is performed with the observance of all the rules given. (See
the Summary.) The index-finger of the left hand is put into the
mouth, in order, in the vestibulum oris, to guide the point of the
needle submucously between the ascending branch of the lower jaw
and the tuber maxillare. At this time the mouth of the patient is
closed. We refer once more to the importance of the rules for direc-
tion given above (Fig. 205). If they are not regarded, and, for ex-
ample, the point of the needle seen from in front points too far toward
the median line, then, instead of getting into the foramen ovale, we
get into the tube and the solution runs into the pharynx.
Q-37
Fig. 23 3–Instrumentarium for injection of gasserian ganglion (Windler, Berlin): a,
Needle, Io cm. long, o.8 mm. thick. Nickeled steel with short sharp point a' and movable
gauge a”; b, fine needle for skin anesthesia; c, 2 c.c. record syringe; d, metal centimeter
measure (reduced). (Härtel.)
“The ease or difficulty of performing the puncture is entirely de-
pendent on the anatomic relationships of the foramen ovale concerned.
If difficulties appear, then they always recur in the same patient, while
the puncture once performed Smoothly always succeeds a second time.
As the foramina ovalia are usually different on the two sides, even in
the same individual, it may happen that the puncture is difficult on
one side and easy on the other. .
“If one makes a good anesthesia of the skin, then the penetration
of the soft parts of the cheek and of the zygomatic fossa is completely
painless. Even the striking of the needle against the planum infra-
temporale causes no pain. On the contrary, the soft parts, situated
medially from the foramen ovale in the vicinity of the tube and of the
pharynx, are extremely sensitive. With inexact localization of the

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 573
pain on the part of the patient, this sensitiveness may simulate for
us the reaching of the nerve and lead to false passages. The touch-
ing of the third branch, for the most part, incites distinctive sensations
in the area of distribution of this nerve (lower teeth, tongue, also the
region of the ear; compare Table I), which are stated partly only as
paresthesia, partly as distinct pains. If this pain produces annoyance,
then a novocain injection already undertaken may greatly relieve its
further advance. After introduction of the needle into the foramen
ovale, feeling is experienced in the area of distribution of the second
branch (upper teeth, upper lip, palate, etc.). But there are many
patients who are not in condition to give any definite localization of
the pain, So that one is guided only by the anatomic landmarks by
contact with the bone and the determination of direction.
“The needle is shoved forward to a depth of 1% cm. into the fora-
men ovale. No further bone resistance should occur, otherwise we are
not in the correct axis, and must repeat the puncture in somewhat
altered direction. If we should get emission of fluid, then we must
draw the needle back a little. The injection takes place quite gradually
drop by drop. The pressure to be used with it is reasonably strong.
On stronger resistance one should guard himself against forcing the
solution forward in an explosive manner, but should move the needle
forward or back somewhat and then try to inject.
“Immediately after the injection of the first decigramme of the
solution the puncture pain subsides. The injection of alcohol is felt
as a burning and glowing in the entire half of the head. We found the
injection of alcohol was almost painless if one or Several days pre-
viously a novocain injection had been made, and we, therefore, recom-
mend in all cases of injection treatment of neuralgia of the trigeminus
the antecedent undertaking of the less painful novocain injection.
“The dose amounts to # to 1% c.c. of a 2 per cent. novocain-Supra-
renin solution (Braun's Höchster tablets) for the local anesthesia, ; c.c.
of 80 per cent. alcohol for the treatment of neuralgia. For anes-
thesia in every case one injects, to begin with, ; c.c. of a 2 per cent.
novocain solution in order to test the anesthetic efficacy of the solu-
tion. For small operations this dose is sufficient; for greater interfer-
ences of longer duration the higher dose is necessary.
“We judge the success of the puncture from the anesthesia that
takes place, which, as a rule, is present momentarily after the in-
jection. Only in a few cases does it appear later (up to five minutes).
If then no anesthesia has resulted, the puncture is to be pronounced a
failure and to be repeated.
574 LOCAL ANESTHESIA
“Up to the present time the conduction anesthesia of the ganglion
Gasseri has been used in 16 Operations. In 9 cases the ganglia of
both sides were anesthetized. The operations performed were the
following: resection of the upper jaw, 6; extirpation of the tongue, 2;
orbital tumor, I; extraction of foreign body in the orbit, I; Sarcoma
of the nasopharynx, 2; plastic operation on the masseter, I; minor jaw
operations, 3. Further, for the purpose of the treatment of neuralgia,
27 injections of novocain or alcohol into the ganglion Gasseri were
undertaken on 14 patients. If we reckon singly those cases in which
the foramen ovale of the same side was punctured several times (repe-
tition of injections for neuralgias), then there were 39 cases of puncture
of the ganglion Gasseri; among these the puncture Succeeded easily
after one or two attempts in 28 cases; with difficulty, so that the punc-
ture succeeded only after several efforts, in 7 cases. In 4 cases, after
several injections, no certain anesthesia appeared in the trigeminus
region of the side concerned, so that here it remains questionable
whether the ganglion Gasseri had been reached. These last 4 cases are
those of 3 patients with neuralgia of the trigeminus and I patient with
carcinoma of the tongue, in whom, on injection of both sides, the left
side did not become completely anesthetized.
“Anesthesia occasioned by the injection of novocain or alcohol into
the ganglion Gasseri is extended to the entire area of distribution of the
trigeminus. As this area is still by no means to be looked upon as com-
pletely known, and besides is subject to variability, the ganglion in-
jections are fitted to make important contributions to the study of the
sensibility of the trigeminus. Until now the extent of the sensibility
of this region was determined, either through anatomic preparations
of the finest nerve-endings (Zander, Frohse) or by examinations on
patients, from whom the ganglion Gasseri was removed by operation
(F. Krause). By ganglion anesthesia these methods should be sup-
plemented valuably and conveniently. A complete elaboration of
this subject is undertaken in conjunction with a neurologist, Doctor
Simons (Oppenheim clinic).
SUMMARY
“(1) The method of intracranial conduction anesthesia of the
ganglion Gasseri insures the possibility of making the entire half
of the head innervated by the trigeminus completely anesthetic by
means of the injection at one point of small quantities of novocain-
suprarenin solution, and likewise, by means of bilateral injection, the
united areas of each trigeminus. The anesthesia takes place at once
THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 575
and continues on an average one and one-half hours. In a majority
of chiefly very extended operations on the facial portion of the skull
the method was used with the best results, partly alone, partly in
conjunction with infiltration of the marginal areas.
“(2) Uncomfortable collateral effects of the injection (sleeping con-
dition, vomiting, pains in the head, etc.) appeared only in isolated
cases, in consequence of the use of a large dose and of careless injection
technic, and are avoidable by correct dosage and exact observance
of the technical rules set forth by the author.
“(3) By the possibility of the direct puncture of the ganglion Gas-
Seri the injection-treatment of trigeminus neuralgia receives a supple-
ment of value, which in severe cases permits the avoidance of the
operation for the extirpation of the ganglion. According to experi-
ences up to this time, novocain injection into the ganglion gives good
results. The injection of alcohol into the ganglion is physiologically
similar in its action to extirpation of the ganglion, so far as can now be
determined. As, however, the danger of the formation of neuropara-
lytic corneal ulcers is not to be avoided with certainty, the alcohol
injection of the ganglion Gasseri, like the Krause operation, is to be
reserved for the most severe and desperate cases only; for the other
cases the method to be chosen remains the injection into the nerve-
trunks, which is to be made as far as possible an endoneural one, ac-
cording to the exact anatomic and technical directions given by the
author.
“(4) In a number of cases the author has succeeded in puncturing
the foramen rotundum directly from a puncture point situated on the
inferior orbital margin, and in obtaining an immediate complete anes-
thesia in the region of the second branch of the trigeminus by injecting
a Small quantity of novocain-suprarenin solution. He has tested this
anesthesia in a series of operations, and recommends this puncture
especially for those cases in which for anatomic or pathologic reasons
the other ways to the second branch are inaccessible.
“(5) Concerning the methods of the conduction anesthesia of the
branches of the trigeminus practiced until now chiefly by Braun and
Offerhaus, anatomic studies and clinical experiences are reported. The
good applicability and extraordinary practical significance of these
conduction anesthesias are demonstrated in the majority of the
operative reports of the ‘Klinik.”
Regarding the after-effects of an injection of the gasserian ganglion,
Härtel has already accumulated sufficient clinical material from which
to make reliable observations.
576 LOCAL ANESTHESIA
In 5 cases there was dilatation of the pupil which lasted for about
one-quarter of an hour, and once after an alcohol injection there was a
transient contraction of the pupil. Twice after the injection of novo-
cain there was a paralysis of the abducens, which disappeared in a
short time. This, as Härtel states, is no doubt the result of a diffu-
sion of the solution into the lateral wall of the sinus cavernosa and
reaching these nerves in this position. (See Figs. 208, 209.)
Following these experiences smaller caliber syringes were used,
which permitted slower injections; since this change these disturb-
ances had not been reported. Occasionally a transitory paralysis of
Fig. 234.—Result of removal of one-half of inferior maxilla under regional anesthesia for
malignancy. (Case of Prof. Matas.)
the masseters occurred, which, however, was not annoying and, on
double injections, a dropping of the jaw occurred, but there was no
masseter disturbances following alcohol injections.
In his early experience certain disturbances of a general nature
occurred, but, upon the change of technic and slower injection of a
quantity not to exceed 14 cm., these disturbances did not recur.
Härtel insists that all injections of alcohol or novocain must be
slowly made, with the patient recumbent; if alcohol, this position is
maintained for at least one hour afterward, and if for any reason the
head is elevated it must be raised by assistance and not by the patient.
An explanation of disturbances, which occurred in patients who set

THE HEAD, SCALP, CRANIUM, BRAIN, AND FACE 577
up, is probably to be found in the fact that the solution may be sucked
out of the cavum Meckeli, through the porus trigemini, into the sub-
arachnoid space of the posterior cranial fossa, and there came in con-
tact with the vagus producing vomiting, etc.
In 3 cases following novocain injections herpes appeared at the
corner of the mouth; this, however, was without other disturbance, and
disappeared after a few days. In 1 case of alcohol injection in a
woman who had previously suffered from diabetes, but was free from
sugar at the time, the herpes was of greater extent and reached to the
cheek and eyelids; in this case there was also desiccation of the
anesthetic cornea. From this experience, Härtel concludes that pre-
Fig. 235—Front and side view, showing result of removal of one-half of inferior maxilla
for malignancy. (Case of Prof. Matas.)
caution should be exercised in injecting diabetic patients, and that
after alcohol injections the same precautions should be taken for
protection of the cornea as after extirpation of the ganglion; this is
also a strong point in proving that alcohol injections have a decided
destructive influence upon the ganglion and simulate very closely the
same results obtained following its removal. In 5 cases following
novocain injections there was pain in the head for several days follow-
ing, which Härtel attributes to an aseptic meningitis, and in I case re-
ported by Härtel there was a septic meningitis; the termination of this
case is, however, not given. This result, he believes, due to the use
of a solution made from tablets, and concludes that only those solu-

37
578 LOCAL ANESTHESIA
tions prepared in ampules should be used. This, however, appears
to me as hardly the explanation, as a tablet solution can be rendered
as absolutely sterile as when prepared in any other way. This is of
interest in connection with the fact that more recently, in the English
literature, appeared a report of extensive sloughing occurring following
the use of an old but re-sterilized solution of novocain, which result
was repeated when again tested on the arm of the operator.
As the ganglion injection is a practically new departure, it is to
be expected that difficulties and unpleasant results may occasionally .
be encountered, and further emphasizes the fact that these injections
are not to be indiscriminately used for all purposes, but only under
definite indications, and when compared with the results obtained from
operations upon the ganglion for neuralgia these unpleasant Sequelae,
with a possible occasional serious complication, will bear the most fa-
vorable comparison and should be regarded as minor considerations.
It is to be expected, also, that as experience increases and technic
improves that many of the unpleasant disturbances may be avoided.
In this connection the injection of the ganglion is not unlike the
early history of spinal analgesia—both are made in dangerous ground
(the fifth very strongly resembles a spinal nerve.) It is to be expected
that further experience will teach us how to avoid unpleasant results.
As a final word of advice for making deep injections into the
trunks of the fifth nerve or at their foramina of exit, aside from the
information contained in the preceding pages, it will be found of great
help, as suggested by Braun, to have near by a skull set in the same
position as the patient's head to further guide one in the accurate pas-
Sage of the needle.
CHAPTER XXIII
THE ORGANS OF SPECIAL SENSE WITH DENTAL
ANESTHESIA
THE EYE
COCAIN was first used as an anesthetic in the eye, brought forward
by Koller in his epoch-making announcement in 1884, and although
many other agents have since been introduced, each having claims in
One or the other direction, still cocain remains the anesthetic of choice
in this particular field, and will be the agent considered here in discuss-
ing the various ophthalmologic operations.
For a consideration of the different drugs as substitutes for cocain
and their particular advantages, see chapter on Local Anesthetics.
A few brief remarks regarding the use of cocain in a general way will
first be made. g
The prolonged or repeated use of cocain in the eye as a means of
controlling pain is objectionable on two grounds: First, the hazi-
ness produced in the Superficial cells of the cornea by its continued
action, made worse when combined with the use of coagulating anti-
septics, such as bichlorid of mercury (see chapter on Cocain); and,
secondly, in chronic conditions requiring its repeated use, particularly
when placed in the hands of the patient, may lead to the formation
of a habit. The first objection raised against it in the early history
of its use has been largely overcome by a better knowledge of its action
gained by experience leading to its more judicious and skilful use.
The slight cloudiness which is seen to follow the repeated applica-
tion of cocain to the cornea was first observed by Koller; this, however,
clears up after a short time, but is most marked and persistent when
bichlorid of mercury is used as a cleansing and antiseptic wash in the
strengths ordinarily employed (I : 4ooo-6000).
Koller undertook experiments upon rabbits to determine the cause of
this action (“Ref. Hand Book Med. Sci.,” 1901, vol. iii, p. 156). Cocain
was instilled into one eye and the lids closed and held together with
forceps; the other eye, into which no cocain had been instilled, was
held open with an eye speculum. After some time it was observed that
the eye held open showed drying and loss of superficial epithelium,
579
58o LOCAL ANESTHESIA
while the cocainized eye showed very little change; from this it was
concluded that the hazy changes seen to occur were not due solely
to the action of the anesthetic. His views on this point were further
substantiated by other observers. -
It is highly useful in any examination of the eye, where pain, pho-
tophobia, and lacrimation would otherwise render an examination ex-
tremely difficult, if not impossible, as in cases of conjunctival or cor-
neal troubles, superficially situated foreign bodies, injury from chemical
irritants, etc. When used for this and other purposes it is better to
make several applications of weak Solutions, o.50 to I per cent., than
to use stronger, 4 to 5 per cent. Solutions, and, where stronger Solutions
are necessary for operative purposes, it is better to precede their use
by the application of a few drops of a weak solution, as the contact of
strong solutions produce a burning irritating pain of Some seconds
duration before anesthesia sets in. Its use for pain which might pos-
sibly be of glaucomatous origin should be carefully avoided, as it has
repeatedly been proved to hasten the development of a threatened
glaucomatous attack. An objection raised by Some operators against
cocain in cataract operation is that it renders the eye so hypertonic
as to make the expression of the cataract more difficult; of recent
years, however, this objection has been overcome by more skilful
methods, and, on the contrary, its use has many advantages, the
dilation of the pupil making iridectomy unnecessary by avoiding
prolapse of the iris. The use of cocain and other local anesthetics
in all ophthalmologic operations has gradually extended, until now
the use of general anesthesia has been reduced to a minimum and by
some is almost entirely discarded.
In all operations upon the lids a triangular or crescentic line of in-
filtration made subcutaneously with o.25 to o.50 per cent. Solutions,
with or without adrenalin, as indicated, will block off the operative
area and secure a perfect anesthesia (Fig. 236).
In chalazion a light infiltration made deep under the subcutaneous
tissues just under the growth, combined with one or two applica-
tions of a 2 to 5 per cent. Solution over the region, will suffice to render
the field anesthetic.
While all operations upon the conjunctiva and cornea may be made
perfectly painless by instillations, in such operations in which the iris
is to be handled or cut, this is not always successful by instillations
alone, and when used it is necessary to use strong solutions, 4 to 5 per
cent., and begin about twenty to thirty minutes before the time for
operation, instilling a few drops every five minutes, allowing it ample
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 581
time to be absorbed and affect the deeper parts. During this time it
is necessary to keep the eye closed to prevent evaporation and drying
of the cornea. The difficulty of rendering the iris absolutely anesthetic
by this method led surgeons in the earlier use of cocain to inject some
of the solutions into the anterior chamber after the corneal section,
a method which has now been almost entirely superseded by the sub-
conjunctival injection. This method was practiced by Koller as far
back as 1885, and is carried out as follows: After several instillations
into the conjunctival sac to render this and the cornea anesthetic, a
speculum is inserted, and the conjunctiva seized by means of a mouse-
tooth forceps; three points of injunction are usually selected, one just
below the cornea and one on each side just below the middle line; it
T -
Fig. 236.-Method of anesthesia of upper eyelid. (Braun.)
is necessary that these sites be so chosen that the resulting edema will
not interfere with the operation. At each point 2 drops of a 5 per cent.
solution are injected, care being taken that the needle does not pene-
trate into the subconjunctival layers, which would result in too
much edema. After these injections the eye is closed for five minutes,
by which time some of the edema subsides and the solution has been
given time to act and the iris is thoroughly anesthetic, when the opera-
tion may be undertaken.
For the removal of cataract several instillations at intervals
of a few minutes of a 5 per cent. solution, keeping the eye closed during
the interval, will usually suffice; but when it is necessary to handle or
operate upon the iris, these instillations should be supplemented by
subconjunctival injections of 2 to 5 per cent. solutions.
For operations upon other parts, tendons or muscles, after the

582 LOCAL ANESTHESIA
preliminary superficial anesthesia, the conjunctiva is seized with for-
ceps just over the point of operation, and the point of the needle is in-
serted as deeply as possible into Tenon's capsules and 2 or 3 drops
injected at the point of the intended operation.
The eye is now closed, and after a delay of five to ten minutes the
tendons can be painlessly divided; in cases where it is necessary to ad-
vance the tendons this is not entirely free from pain, as the necessary
pulling on the central and deeper parts of the muscle cause pain, as
these have not been reached by the anesthetic Solution.
In operations upon glaucoma, acute and chronic, Koller recom-
mends 5 per cent. Solutions of cocain containing 2 per cent. pilocarpin,
and states that after an experience with this method of over ten
years he has not met with any bad effects which could be attributed
to the injection, and the results obtained compare favorably with
those obtained by any other method.
Professor Koller, in speaking of the action of cocain as a mydriatic, as
well as its use in certain inflammatory conditions, states the following:
“The pupil-dilating property of cocain is of great value in ophthal-
moscopy. While the dilatation is sufficient in the dark chamber to
allow a satisfactory examination it does not have the blinding effect
of belladonna, the pupil all the time responding to light.
“This is due to the fact that cocain dilates the pupil by constricting
the blood-vessels of the iris, but leaves the sphincter intact; besides,
the accommodation is hardly interfered with.
“The pupil-dilating power of cocain, if combined with that of
atropin, is invaluable in cases of iritis. *
“The mydriatic effect of this combination is stronger than that
of any other drug or any combination of drugs; it counteracts both
forces that contract the pupil, the sphincter and the blood-vessels.
(Hyperemia of the iris tends to contract the pupil by stretching the
tortuous course of the iris arteries, while the blood-vessels, when
empty, return to their tortuous course and so dilate the pupil.)
“The anemia of the blood-vessels is a strong check to the inflam-
mation, the pain ceasing mostly after a few instillations and the dura-
tion of treatment being greatly shortened. The writer uses a mixture
of equal parts of a I per cent. Solution of Sulphate of atropin and a 5
per cent. Solution of hypochlorate of cocain; at first he instils every
ten minutes until the pupil is dilated (three to four instillations are
necessary), then only three times a day.
“The combination of the two drugs is also efficient in cases of
cyclitis.”
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 583
For enucleation it is necessary to carry the injection deep down
around the origin of each recti muscle. The Superficial parts are first
anesthetized in the usual manner by instillations and subconjunctival
injections, combining adrenalin with the latter as well as with the
deeper injections around the recti muscles, using not over I or 2 drops
of I: Iooo adrenalin at each point of injection, making use of a 2 to 5 per
cent. solution of cocain. After the anesthesia of the Superficial parts the
conjunctiva is divided and the orbit opened; the needle is then passed
deep down to the origin of each recti and 2 or 3 drops deposited at
each point; when this has been completed at all four points, and a
delay of a few minutes allowed for thorough saturation of the tissues,
the anesthesia should be complete and the operation proceeded with.
The advantages of combining adrenalin with the cocain here is
decided in lessening the amount of hemorrhage which is otherwise fre-
quently profuse, as well as prolonging and lessening the possibilities
of toxic symptoms arising through absorption. Operators differ in
their views regarding the advisability of the use of adrenalin in other
operations, but most all agree that it is of advantage in such operations
as enucleation, tenotomy, and advancement of the tendons, where it
both intensifies and prolongs the anesthesia. The injection of the
solution into the insertion of the tendons is not desirable as it causes
too much swelling, but during the operation pledgets of cotton wet
with cocain and adrenalin can be laid upon the field.
In operations for pterygium adrenalin appears to be contra-indi-
cated, as its blanching effect renders the outline of the growth less
distinct. -
In the removal of foreign bodies adrenalin would seem contra-
indicated, except where the hemorrhage is severe, as slight hemorrhage
may prove of benefit by washing infectious material out of the wound,
which might otherwise enter the deeper tissues; on the same grounds
cocain, on account of the ischemia it produces, might prove objection-
able and be replaced here by some other agent which does not cause
such vasoconstriction.
As a general thing, adrenalin should be very cautiously used about
the eye; its too free use, or too strong solution, may give rise to an
aching pain or produce disturbances in the cornea. When used by
instillation it should not exceed a few drops of a I : Io,000 to I5,OOO
solution.
In all operations upon the eye with cocain care should be exercised,
as idiocyncrasies are frequently encountered and may give rise to
unpleasant and often toxic symptoms.
584 LOCAL ANESTHESIA
For a diagram of the nerves of the eye, see Fig. 167, and for a
further description of the anatomy of these parts, see chapter on the
Head. In addition to the above two special methods of anesthesia
are frequently employed for enucleation, the methods of Löwenstein
and Siegrist.
Löwenstein anesthetizes the ciliary ganglion and retrobulbar struc-
tures by a retrobulbar infiltration. After first anesthetizing the con-
junctiva by infiltration, a point on the outer orbital margin is selected
and a long, fine needle entered at this point and passed obliquely in-
ward and backward behind the bulb (see “Anatomy of the Orbit” in
chapter on the Head), injecting the solution as the needle is advanced
until a depth of about 4% cm. has been reached. Care is exercised not
to puncture the bulb by displacing it inward with the finger and by
a lever-like motion of the needle to determine that it is free in the re-
trobulbar space; at this point from I to 2 c.c. of a I per cent. Cocain
solution is injected.
In the method of Siegrist the same purpose is accomplished by
using curved needles, which are passed through the conjunctiva from
four puncture points around the margin of the orbit and passed around
the bulb into the retrobulbar tissues.
THE EAR
From a study of the nerve supply of the auricle it will be seen that
a horseshoe-shaped injection, embracing the ear from below, made
subcutaneously and carried down beneath the attachment of the deep
fascia to the bone, will reach and block the entire nerve supply to
these external parts, or the procedure, as illustrated in Fig. 237, may
be adopted.
Where the operative field involves the external parts of the auditory
canal supplied by the auricular branch of the pneumogastric an
injection should be made deep at the root of the ear, on its posterior
aspect, where this branch of the pneumogastric passes upward and
forward through the auricular fissure between the mastoid process and
the auditory canal.
This simple procedure will permit of any operation on the external
parts. Solution No. I will be found sufficiently strong for this pur-
pose; the addition of adrenalin will render the field completely ischemic.
In exceptional conditions of great vascularity a procedure, used by
Prof. Matas and reported in the following case, will be found of great
value:
“The utility of Corning's principle of incarceration was most for-
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 585
cibly impressed upon my mind in 1890 in operating upon an extremely
vascular nevoid angioma of the entire auricle.
“In this case the ear presented elephantine proportions, and pul-
sated with the arterial and venous blood by enormously dilated blood-
vessels; one of the caverns ruptured by ulceration and the patient
nearly succumbed after a frightful hemorrhage. The external carotid
was ligated, but this was followed by only temporary improvement. A
few weeks afterward the ear was cocainized, resected, and bared com-
pletely of its tegumentary covering, including the afferent blood-ves-
sels, which were all secured and ligated by a very simple procedure.
This consisted in the injection of a 4 per cent. solution of cocain
(o.5 ocf 1 per cent. would have been sufficient) into the peri-auricu-
Fig. 237.-Points of injection for anes- Fig. 238–Van Eicken's method of
thetizing external ear. (Braun.) injection for anesthetizing external audi-
tory canal. (Braun.)
lar tissues at the root of the ear, until a complete circle of cocain solu-
tion had been formed around it. Four hair-lip pins were then intro-
duced at equidistant points, so as to transfix sections of the circle.
These were used as binding posts to hold a thin rubber band, which was
wound around each pin, and the rubber was stretched tightly around
the pedicle. The pulsations in the ear ceased immediately, and, with
the arrested circulation, a complete anesthesia of the auricle followed.
which permitted the operation to be performed throughout without
pain or hemorrhage.”
For the anesthesia of the external auditory canal and tympanum,
many operators in this field have worked out various plans by which
operations on these parts may be painlessly performed.
--
--

586 LOCAL ANESTHESIA
Von Eicken suggests the following:
For external parts he begins by Spraying with ethyl chlorid, and
then follows with an injection of cocain and adrenalin Solution in the
posterior fold of the pavilion, under the cartilage of the floor of the
canal. The needle is directed upward and backward to reach the point
of emergence of the auricular branch of the pneumogastric, which is
the sensory nerve of the posterior part; without completely withdraw-
ing the needle, the point is then forced toward the anterior and deeper
part of the canal to attain the auriculotemporal filaments (Fig. 238).
Complete anesthesia of the external canal is thus obtained in one
or two minutes. The tympanum is next anesthetized by injecting
the solution into the skin of the deeper part of the canal.
While the above may prove successful, it has not appeared to us
that the use of ethyl chlorid about the external auditory canal was
very satisfactory, as its application here has seemed unpleasant to
the patient.
The following plan by Tiefenthal appeals to us more, and is
equally simple; a combination of the two, by injecting the auditory
branch of the pneumogastric as recommended above, followed by
anesthesia of the drum as practiced by Tiefenthal, may prove more
satisfactory.
Tiefenthal recommends that 4 drops of a 20 per cent. Solution of
cocain with I drop of adrenalin (1 : 1000) be placed in contact with
the drum membrane for fifteen minutes. This produces a slight reduc-
tion of sensibility, but insufficient for paracentesis. Then, with a
small syringe having a fine, angular needle, he injects through the
lower part of the membrane 2 to 4 drops of a 5 or Io per cent. Solution
of cocain with adrenalin. After a few seconds the membrane appears
whitish gray from the anemia of the tympanic cavity, the anesthesia
is complete, and paracentesis may be performed without pain or
hemorrhage.
Professor Neumann, who has done much work with local anesthesia
on the ear, secures anesthesia in much the same way. The operative
possibilities are not, however, limited to these simple procedures, mas-
toid operations being performed with equal success. For this purpose
it is necessary to have a strong syringe. Neumann used a metal syringe
with specially modified needle, but any strong syringe and needle will
do. He recommends a 1 per cent. eucain solution, with 5 drops of
tonogen (an Austrian preparation of adrenalin) to each cubic centi-
meter for infiltration of the soft parts. The deeper infiltration about
the periosteum is done with a 1 per cent. Solution of cocain and 5 drops
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 587
of tonogen to each cubic centimeter. The solutions are warmed before
injection to about 45° C. to facilitate their diffusion.
The entire region over the mastoid is now thoroughly injected sub-
cutaneously with the eucain solution, from the base to the apex and
forward to the ear (Fig. 239); some of the solution is then injected
subperiosteally; the ear is now drawn forward, and the anterior wall of
the mastoid process injected subperiosteally down to the bony termina-
tion of the auditory canal (Fig. 240).
Through a speculum, which is now inserted into the ear, I c.c. of
the cocain solution is injected into the superior wall of the auditory
canal, at the point of junction of the bony and cartilaginous portions,
Fig. 239–Points of injection for sur- Fig. 240-Point for deep injection
rounding operative field with zone of anes- behind ear. (Braun.)
thesia for mastoid operation. (Braun.)
another syringeful into the inferior wall, and slightly less into the
anterior and posterior walls. These injections must be made beneath
the periosteum, and in such a manner that they produce a distinct
bulging or protrusion, which disappears as absorption takes place. A
small pledget of cotton, saturated with 20 per cent. cocain solution,
is now inserted into the tympanic cavity through the perforation in the
tympanic membrane (which always exists in these cases). This is
not removed until the antrum is opened during the progress of the
operation.
After a delay of about fifteen minutes the operation may be begun.
It is recommended that in cutting the bone only a very sharp chisel
should be used, which is held as flat as possible and the bone shaved off

588 LOCAL ANESTHESIA
in this manner, and never holding the chisel perpendicular, which would
produce too much concussion and would be very trying to a conscious
patient. If preferred, a burrow or other drilling instruments may also
be used. While the above description is for the regular mastoid opera-
tions, it is by no means limited to this class of cases, but may be used
equally as well in acute mastoiditis.
NOSE AND THROAT
The present-day operator little conceives of the difficulties experi-
enced in certain departments of surgery in the days before the intro-
duction of cocain and its congenors, even after we had the many benefits
conferred by general anesthesia. As illustrative of these conditions,
and the efforts many were making toward finding suitable local anes-
thetics, I quote the following by Dr. Wm. C. Glasgow, of St. Louis,
read before the American Laryngological Society at New York, 1879.
The same difficulties were experienced in all fields of work where local
anesthetics are now so freely used.
“The need of an agent by which the excessive sensibility and the
spasmodic contractions of the larynx caused by the introduction of
instruments can be controlled has been fully experienced by every
laryngeal Surgeon.
“The common method of deadening sensibility by the repeated in-
troduction of the sound is tedious both to operator and patient.
Some cases can be readily operated upon with slight preparation, but
still we find others where the most persistent education gives little
result.
“The use of bromids, potassium, sodium, and ammonium, when
applied locally and taken internally, produce a certain effect in dimin-
ishing the sensibility, but their use is unsatisfactory when the produc-
tion of anesthesia of the larynx is desired. The same may be said of
ice and the various astringents, as, for example, tannin. The morphin
and chloroform solution of Professor Bernatzic, given by Turch and
as used by Bruns and Schroetter, does certainly produce the desired
result, but as the constitutional effects of morphin are marked long
before the anesthesia of the larynx is sufficient it cannot be regarded
as a safe remedy or one that can come into general use.
“In 1871, fresh from the instruction of the Vienna school, I used this
solution for the first and I trust for the last time. The patient was a
young girl, with papillomata of the larynx. I applied the solution of
Bernatzic after the manner taught by Schroetter. The constitutional
symptoms preceded the local anesthesia fully one and one-half hours,
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 589
and they became so grave during the operation that it had to be sus-
pended and the most energetic measures employed to combat the toxic
efforts of the drug. The local anesthesia, however, was complete.
“I have seen the morphin solution repeatedly used with great suc-
cess in the Vienna clinic, and it may be possible that my patient was
peculiarly susceptible to the drug; still, the method is subject to too
many risks ever to become popular.
“During the past winter I have been experimenting with two reme-
dies, both of which produce, in a measure, not only the desired anes-
thesia, but also relief from pain. I refer to hydrate of chloral and
carbolic acid. Both remedies have been extensively used in throat
practice, but, as far as I am aware, they have never been suggested
or used for the purpose of producing anesthesia of the larynx, etc.”
The above gives a brief idea of earlier difficulties encountered and
the efforts made by the pioneer operators in their search for a satis-
factory local anesthetic; up to the very time of the discovery of cocain
this search had gone ceaselessly on; the literature of the precocain
period is full of similar reports, and many different measures utilized
to produce the, until then, unsatisfactory local analgesia.
It is particularly to the surgeon specialist, and especially in ophthal-
mology and nose and throat surgery, that local anesthesia has proved
a great boon to the operator, reducing to simple office procedures many
operations which formerly required a sojourn in an institution and a
general anesthetic for their performance. Also, for the use of such
instruments as sounds and dilators, much tedious and trying practicing
of the patient is now done away with where the parts can be readily
anesthetized. The examination of sensitive and inflamed parts can
also be carried out without the discomfort to the patient formerly
necessary. Notwithstanding the many advances in local anesthesia
during the last few years, and the newer and safer agents introduced,
cocain still remains the anesthetic of choice among the great majority
of operators in these special fields. This is no doubt due to the fact
that cocain, being the first agent introduced, the methods of applica-
tion necessary to its success have been studied and perfected, until
now it is hard to displace it from its firmly established position. How-
ever, we are firmly convinced that the time and trouble required to
understand the slight differences necessary in the technic of the use of
some of the safer agents, particularly novocain, to insure the same de-
gree of anesthesia will be more than amply repaid by the occurrence of
fewer sequelae and toxic symptoms. For this reason, we especially
urge the reader to consider carefully the description of these different
590 LOCAL ANESTHESIA
agents described in the chapter on Local Anesthesia, and that part of
the chapter on Technic dealing with the action of concentrated and weak
Solutions as it is particularly applicable to nose and throat surgery.
In our discussions here we will follow the trend of the present time
and describe the operative procedures under cocain.
It is not alone in operative work that local anesthesia may prove of
value in this field, as it may be used to advantage in a certain lim-
ited number of cases in a diagnostic way; in reflex neurosis, starting
from the nose, the exact location of the trouble can often be definitely
determined, as an application of cocain to the starting-point relieves
the reflex (asthma, etc.).
There are three methods of applying cocain to these parts in Com-
mon use—by sprays, swabs, and infiltration (cataphoresis rarely).
In using a spray it is advisable, as a rule, to use only weak Solutions
(2 per cent.) in graduated bottles, so that the exact quantity used may
be definitely known to avoid the possibility of poisoning, having the
patient to expectorate any accumulations in the mouth or pharynx in-
stead of Swallowing them. Weak solutions, applied repeatedly at in-
tervals of a few minutes, will accomplish as much as stronger ones and
eliminate dangerous possibilities; the first application, by constricting
the blood-vessels, produces a certain degree of ischemia when subse-
quent applications upon the ischemic area act more profoundly and
absorption is greatly lessened. For application with a swab stronger
Solutions are advisable, 5, Io, or 15 per cent., although many operators
use highly concentrated solutions up to 50 per cent., as will be spoken
of later.
For application to the larynx it is usually advisable to use solutions
of at least 20 per cent. For infiltration it is usually necessary to use
from o.50 to 2 per cent. Solutions.
Adrenalin plays an active part in nearly all these applications, but
it should be cautiously used, as it is an agent capable of producing
considerable disturbance, and many symptoms erroneously attributed
to the anesthetic are in reality due to the adrenalin. In this respect,
it may be said that it often produces a peculiar tight feeling or pain
in the head when too freely or injudiciously used.
The advisability of administering to all patients about to undergo
an operation of any severity upon these parts some preliminary seda-
tive a short while before, the same as is advocated for any general Sur-
gical procedure under purely local means, has been discussed by rhinol-
ogists. The objections found with the usual morphin and scopo-
lamin is that most of these patients are operated in the sitting position,
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 591
and while the medication accomplished the desired end in relieving
anxiety and uneasiness, it often makes the patient so drowsy that they
nod about and are unsteady in the chair. Leshure makes use of the
following, which is given by mouth about one-half hour before opera-
tion—morphin, 4 gr.; hyoscin hydrobromatic, Tºo gr.; and strychnin
Sulphate, sº gr., which is practically equivalent to our morphin and
scopolamin, with the addition of the strychnin.
Miller recommends the following—sodium, potassium, and ammo-
nium bromid, aā Io gr.; Spiritus ammoniae aromaticus, I dram; aqua
q. S.; this is given a short while before operation.
If nausea occurs during the progress of the operation it is usually
relieved by the inhalation of ammonia, and with any evidence of
faintness the head should at once be lowered.
In operations upon the anterior end of the nose in such procedures
as the removal of dislocated septal cartilages infiltration is usually
necessary, using o.5o to I per cent. Solutions of cocain with adrenalin,
injecting the solution beneath the skin and mucous membrane surround-
ing the field sufficient to produce a moderate degree of edema, and al-
lowing a few minutes to elapse before beginning the operation.
A somewhat similar technic can be followed in dissecting out por-
tions of the lateral cartilages, when these encroach upon the breathing
space; the injection is made beneath the skin and mucous membrane,
particular attention being paid to the region of the nasopalatine nerves,
for if these are not rendered anesthetic pain will be complained of in
the front teeth when those nerves are reached.
In the anesthetization of those parts of the nasal tract, septum,
and turbinates, which are usually accomplished by Swabbing the oper-
ative area, many operators of extensive experience and undoubted
ability prefer to make use of very strong solutions, sometimes reaching
50 per cent. and stronger, rather than follow the example of the
general surgeon, whose aim is constantly to reduce the concentration
of the solutions used to the minimum effective strengths. It would
seem to us advisable to use repeated applications of weaker Solutions
rather than such concentrated strengths, but the use of the strengths
in this especial field is not without a rational basis founded upon physi-
ologic laws, as is discussed in the chapter on Principles of Technic.
The merit of the procedure is further borne out by the constantly ac-
cumulating clinical evidence and the skill and ability of those making
use of these practices. Some operators, when operating upon these
parts by means of the Swab, prepare their solution by placing a few
grains of pure cocain crystals in a dish or suitable receptacle and
592 LOCAL ANESTHESIA
moistening them with just enough adrenalin (1 : Iooo) to render them
soluble, claiming better results from this solution, which gives an anes-
thesia of from three-quarters to one hour duration.
In operations upon the septum and turbinates two methods of
inducing anesthesia are in vogue: By packing the nasal cavity with
pledgets of cotton, wet in the anesthetic solution, and allowing them
to remain for about twenty minutes; this may be supplemented later, if
found necessary, by a light application with the Swab. The objection
of this method of packing is that large quantities of cocain are likely
to be absorbed, as the packs come in contact with the entire nasal fossa
and their presence stimulates the flow of mucus, which washes the
cocain down into other parts where absorption takes place. A
much safer and better method is to anesthetize the field by the use
of swabs, and here much skill can be shown in their use; in beginning
the application of a swab upon sensitive parts it can always be pre-
ceded by the use of the spray; after the Swab has been applied, allow
it to remain in position a few moments; as the anesthetic is taken up
it diffuses in all directions, which can be recognized by the blanching
effect upon the tissues; the application is then reapplied within the
margin of this area in much the same way as a skilful Surgeon will
infiltrate the skin; in this way the patient is not conscious of pain
or other discomfort during the anesthetizing process.
Special attention should be paid to any irregularities, such as Spurs
and deviations, to insure reaching all overhanging or posterior Sur-
faces, by bending the applicators in suitable directions. An applica-
tor once used should not again be placed in the Solution, as mucus
and other secretions carried in with it dilute the solution.
The utilization of regional methods of anesthesia has a limited ap-
plication within the nose, by Swabbing the solution in concentrated
form over the trunks of the nerves at their points of emergence upon
the nasal septum. Some few operators recommend injecting the
solution at these points, and while this may in rare instances be
necessary, as in the case of extensive scar formation or other conditions,
the majority of operators find the swab sufficient, as the solution readily
penetrates the overlying mucous membrane and reaches in effective
strength the underlying nerves. (See discussion of the use of concen-
trated solutions upon mucous surfaces in chapter on Principles of
Technic.)
By a study of the accompanying illustrations, showing the course
and distribution of the nerve supply, a knowledge of regional methods
here is readily obtained (Figs. 241, 242, 243, 244).
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 593
The presence of scar tissue occasionally found in the septal mucosa,
the result of previous disease (small-pox, etc.) or injury, may render
the production of perfect anesthesia by means of applicators impossible.
In such cases resort must be had to infiltration; this however, is rarely
necessary.
apt. ethmoidal artery
º
º
A anterior ethmoidal nerve
º a -anterior meningeal art. x
º
r
criºlatº, post ethmoidal/a"
post.art. ºak º artery
nasopalatine nerve *::::ſº ***,
sphenoid bone , * \ * 9 * *
-
*
-
|olfactory nerves
* (media!)
anter, art of
nasal septum
ºf nasal br. of
Q: ºf ethm. nerve”
- mitrous
...”
choana -- - axilla X
- - -> * Nº. atongue
ostium - º - - - [Alingual
rubae T. ºerve x
*† º
alosso.
palatinuš".
Stylo --
glossus
++
glosso-
pharyngea
nerve -
T- mandibula x
A " ; Mylohyoideus x
! / Geniohyoideus x
— f d hypoglossal nerve x
Hyoglossus × grep lingual art.
Chondropharyngeus sublingual art.
reater cornu
of hyoid bone
lingual artery
Fig. 241.-The nerves and arteries of the nasal septum and of the tongue. * =
divided posterior pharyngeal wall. ** = sphenoidal sinus. (Sobotta and McMur-
rich.)
When using infiltration, Killian recommends a regional anesthesia
blocking the septal nerves. He makes the injection at two points—(1)
just anterior to the tuberculum septi in an upward direction, and (2)
at a point just below the middle of the lower border of the middle tur-
binate (Fig. 245).

































38
594 LOCAL ANESTHESIA
The Inferior Turbinate-This is anesthetized in much the same way
as the septum, except that greater difficulties are usually encountered,
particularly when it is large, overhanging, and encroaching upon the
surrounding parts; however, the application of the cocain-adrenalin
solution soon produces a certain amount of shrinkage, making the
posterior lateral nasal arteries
* olfactory nerves (lateral)
Anoster. Taferal …”
lesser palatine art. nasal nerves
". + sphenopalatine A
anterior nasal br. of
!---ant. ethmoid, nerve
anterior lateral nasal art.
ſaiddle nasal concha
*
+a+ \ \ arr
\
w
post pala.
fine nerve superior ſil
\roncha.” 2.
-
infer, nasal
* concha
nasal
septum ×
Mºutº, sº - - -
º | º º
- - * + +
º º incisive
- J canal
* ** + +
- º, mandible x
nºa º & -
lossophar - - . . . - .* * *
grossopharyng, al nerve ton- lingual vallate lingual ". dorsum of tongue
ascending Palatine art. sº. branº, , pººline joicies , great palatine art.
fonsillar br. br. zalafine fonsil anf. palatine nerve
Fig. 242.-The nerves and arteries of the outer nasal wall and of the palate. The
tongue has been drawn out, all of the nasal septum except its lower portion removed, and
the mucous membrane of the faucial isthmus divided along the glossopharyngeal nerve and
the ascending palatine artery. ** = Sphenoidal sinus. * = Divided branches to nasal
septum. *** = Anastomosis between nasopalatine and anterior palatine nerves. * + =
mucous membrane of hard palate. (Sobotta and McMurrich.)
concealed parts more accessible. At times it is necessary to reach
the posterior parts by using a curved applicator passed from behind
through the nasopharynx. Rarely is it found necessary to use infil-
tration, and when this is done great care should be exercised as the
absorptive power of this tissue is tremendous.
























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THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA
595
º
º
º
Fig. 243-Innervation of nasal Septum.
Fig. 244-Innervation of lateral nasal
(Braun.)
wall: I, Olfactory nerve; II, nasal nerve;
III, nasopalatine nerve. (Braun.)
–––Wasal
- fterwe
- A------Points for
* ~~~7 anesthesia
* ,
º
Nasopalatine nerve
Fig. 245-Points of anesthesia for Killian regional method. (Braun.)


596 LOCAL ANESTHESIA
The middle turbinate is usually much simpler, and is treated in much
the same manner.
The nasofrontal duct and antrum of Highmore are operated upon in
the same manner by securing anesthesia by the use of Swabs over the
surfaces to be operated upon.
The uvula presents no difficulties, and is easily anesthetized by a
few applications with the swab or it can be infiltrated.
The lingual tonsil presents some difficulties, and should be anes-
thetized with great care, particularly if the cautery is to be used;
as cocain is destroyed by heat, it is necessary to have the anesthesia
penetrate well beyond the influence of the cautery, passing the Swabs
well down to its base between the folds of the lymphoid tissue.
The nasopharynx is ordinarily rather difficult of operation under
local anesthesia, largely due to its being rather difficultly accessible,
and to its being covered in these cases with tenacious mucus which
protects the underlying membrane. However, certain operations
can be very satisfactorily performed. The anesthesia is accomplished
by swabs passed back through the nose on each side and up through
the mouth; during this procedure care should be exercised not to over-
look the posterior border of the septum.
The ordinary curet is unsatisfactory for operations under local
anesthesia, as the blade wounds the deeper structures, which have
been only imperfectly anesthetized; instead resort should be had to
such instruments as the Schultz adenotome, which are so constructed
as to protect the deeper parts.
The Faucial Tonsil.—This structure, on account of its ready ac-
cessibility, is ordinarily quite easily enucleated under local anes-
thesia, different operators using different methods of anesthesia and
various anesthetic solutions; recently some have advocated quinin and
urea, on account of the absence of after-pain under its use and the
diminished tendency to postoperative hemorrhage.
From our personal experience with this agent we would not care
to recommend it as it is at present used. (See chapter on Quinin and
Urea.) The anesthetizing process is begun by brushing the tonsil,
its anterior and posterior pillars, and supratonsillar fossa with a swab
wet in a strong Io to 20 per cent. Solution of cocain and adrenalin.
A 1 to 2 per cent. Solution of cocain, containing I : Io,000 adrenalin, is
then injected into the anterior and posterior pillars, carrying some
of the solution down under the base of the tonsil. When carefully in-
jected it is not necessary to use more than 40 to 60 minims, which
should result in a perfect anesthesia in a few minutes. As the ton-
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 597
sil is being separated from the pillars and its bed, if any pain is com-
plained of, swabbing over the area will control it.
Hemorrhage is usually very slight, owing to the use of adrenalin,
but if any occurs it must be perfectly controlled before leaving the
case, as it may increase as the effects of the adrenalin pass of:
Larynx and Trachea.—Any applications to the larynx is best pre-
ceded by a preliminary spraying with a 2 to 5 per cent. solution, having
the patient inhale at the time, preferably using graduated bottles.
The superficial anesthesia secured in this way will permit of the
easy use of the swab later, which is used with a 20 per cent. Solution.
Figs. 246, 247–Outline of points of injection for anesthesia of frontal sinus: 1, Penck-
art point of injection for nasal nerve; 2, point of injection on side of cheek for reaching
sphenomaxillary fossa. (Braun.)
To anesthetize the trachea a 5 to Io per cent. Solution is usually
necessary, which is sprayed in at the moment of inspiration, hav-
ing the patient to expectorate any which may accumulate in the
pharynx.
In all operations upon the above-mentioned parts, where the pro-
cedure is at all protracted, the operator is warned of returning sensi-
bility by the return of vascularity and oozing of the parts, which al-
ways precedes the return of sensation and affords time for the applica-
tion of additional anesthetic.
In very extensive operations within the nasal cavities considerable
advantages may often be offered by blocking the superior maxillary
nerve where it leaves the foramen rotundum, as described in the

598 LOCAL ANESTHESIA
chapter on the Head. This could be supplemented by the use of ad-
renalin locally to control the hemorrhage, or, under extreme conditions,
ligating the external carotid artery.
Under certain conditions it may be advisable to use combined
methods of anesthesia, which are discussed under this heading.
For operations upon the frontal sinus the field is embraced in an
area of infiltration, as shown in Figs. 246, 247, carrying the infil-
tration deep down to the periosteum, at the orbital margin, to reach the
supra-orbital and supratrochlear nerves at this point; following this
very light infiltration is necessary laterally and above, but may often
be found unnecessary. Anesthesia of the mucous lining of the sinus
is controlled by a median orbital injection made at point I, for the
technic of which see chapter on the Head.
DENTAL ANESTHESIA
Here all methods of anesthesia find a field of application, from
ethyl chlorid and topical applications down to the more extensive
operations performed under regional anesthesia. Ethyl chlorid is
used in the opening of abscesses and other simple incisions, and is
sometimes employed for extractions. For this purpose the ordinary
container may be used, which sprays one side of the gum at a time,
or a specially devised instrument, with a forked-shaped or two-pronged
tip, which directs the spray to both sides at the same time.
For the purposes of infiltration about four agents are now em-
ployed—namely, cocain, É-eucain, alypin, and novocain—together
with a large number of proprietary mixtures, which contain mixtures
of the above agents with other ingredients in different proportions,
most of them containing adrenalin.
Thymol is one of those agents, and seems preferred by the great
majority of dentists, as this agent combines antiseptic and anesthetic
qualities; in dilutions of I : 2000 it prevents the developments of
bacteria, and in more concentrated solution, I : 200 it is destructive
to most organisms. Dentists frequently make use of this quality as
well as its anesthetic effect by applying solutions to sensitive pulp
cavities; this anesthetic property is quite decided. Experiments upon
animals show that I : Iooo solutions will paralyze the cutaneous nerve-
endings of frogs immersed in it for a short time. As recommended
by Fischer, the proportion in anesthetic mixtures should be about
I : 5000. He prefers the following formula, which he recommends for
infiltration purposes:
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 599
Novocain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I.5
NaCl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.92
Thymol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O.O25
Distilled water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IOO.O
For all practical purposes our solution No. 2 (I and 2 per cent.
novocain), with 5 drops of adrenalinto the ounce, will be found amply
Sufficient, much cheaper, and more satisfactory than the many pro-
prietaries now on the market, or the solution recommended by Fischer
O
D
[. º
bºrº
#
fº
º
E
#
2}}
Fig. 248.-Injection syringe of glass and metal, designed by Dr. Guido Fischer. (See Fig.
249 for explanation of lettering.)
may be used. For injection into the gums specially constructed
syringes with short, stout needles, often directed at an angle, are neces-
sary, as the ordinary syringe and needle will not stand the pressure
needed to infiltrate such dense tissue. The syringe and needles
shown in Figs. 248 and 249 have, after a thorough experience, been
found to fill all requirements, and have been adopted by Fischer.




6oo LOCAL ANESTHESIA
The dental nerves and their areas of distribution are seen in Figs.
144, 160, 161, 162, and 163, and a more thorough description is given
in the chapter on the Head.
It should be remembered that dental anesthesia, when applied
to the roots of the teeth, is practically always a paraneural injection,
and may require ten or fifteen minutes to become effective. These
S
ZZZZZ
Níž
éº:
º
W SS
§:
3.
£
3S
*S
%
J
Fig. 249–Needles, awls, and wrench for injection syringe, designed by Dr. Guido
Fischer. At the left is a considerably enlarged reproduction of the new needle, showing the
details of construction as follows: 1, The hollow needle, either of seamless steel, pure nickel,
gold, or iridio-platinum; 2, body of soft metal for firmly tightening the needle upon the
orifice of the syringe; 3, conical shell of hard metal, open below, from which the soft metal
cone protrudes. This arrangement remedies the deficiencies of the old styles of needles
in which the unprotected soft metal cone could not stand much use, became flattened
easily, and jammed in the hub so firmly that both hub and needle had to be replaced, which
was rather expensive if gold or iridio-platinum needles were used. The new needles are
attached to the syringe absolutely tightly by inserting the needle in one of the hubs (b or c)
and screwing it firmly on the orifice of the syringe. In order to enable practitioners with
sensitive fingers easily to manipulate the hubs, which heretofore were milled, the hubs
b and c, also the middle pieces d and e, are made with hexagonal Connections, so that they
can be conveniently and firmly tightened by a slight turn of the wrench. No force should
be used, otherwise the soft metal cone of the needle becomes unnecessarily worn.
(Fischer.)
&
2
injections should be made subperiosteally rather than under the mucous
membrane, and under considerable pressure, as this solution must force
its way through bony tissue to reach the nerve-fibers at the root of
the tooth.
Before making the injection the surface is cleansed and touched
with iodin. The needle should be entered at a right angle to the mu-














THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 601
cous surface, injecting as the needle is advanced, and slowly pushed
through to the periosteum, which is penetrated, and the needle ad-
vanced a short distance along the bone and well up toward the root of
CZ h
Fig. 250.-Position of needle in mucous anesthesia, aperture of needle pointing toward
the bone: a, Correct position; b, incorrect position. The point of the needle is forced into
the periosteum and to the bone. (After Seidel.)
the tooth; the opening in the neédle point should always be directed
toward the bony surface (Figs. 250, 251, 252, 253), the remainder
of the solution now slowly injected, the needle withdrawn, and the
* * º: --
§ Żºłż sº
2.
%
㺠º
#%
2% º
º
ſº º
Fig. 251.-Position of needle for horizontal injections in several upper teeth: a, Labial
injection; b, buccal injection. (After Fischer.)
finger pressed upon the point of injection for a few seconds. In
those parts of the mouth in which the needle cannot be advanced at
a right angle it must be done obliquely, but should be made as nearly
at right angles as possible.


602 LOCAL ANESTHESIA
º
§º
§§
§§
§
n W N §§ W º
§§§
§§§
(2
Fig. 252.-Position of needle for injec- Fig. 253.−Position of needle for mu-
tion in upper canine: a, Labial injection; b, cous anesthesia in upper first bicuspid.
palatal injection. (After Fischer.) Above is seen the infra-orbital foramen: a,
Buccal injection; b, palatal injection.
|
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º
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§§§ Š->:
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Fig. 254.—Injection in palatal mucous membrane at lateral incisor region. Syringe is held
like penholder. (After Fischer.)



















THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 603
Repeated punctures by the needle are to be avoided when possible,
as two or more teeth can be injected by using a long needle and
advancing it in such a position that the area of injection can be made
to embrace several teeth (Fig. 251).
For injections upon the palatine surface the needle is made to enter
more nearly in the axis of the tooth (Figs. 252, 254), inserted back
from the gum margin, and advanced to a subperiosteal position over
the root apex. In dealing with the upper molars, instead of making
the injection as above, an injection can be made into the posterior pala-
tine canal (regional anesthesia), this injection sufficing for all three
molars, as follows:
On the lateroposterior surface of the tuber maxillare of the superior
maxilla are seen a varying number of foramina, the openings of the
Fig. 255.-Position of needle for injection at maxillary tuberosity. (After Fischer.)
posterior superior dental canals through which the sensory nerve-fila-
ments pass to the three upper molars; before entering these canals the
nerves run downward and forward for a short distance in the submucous
tissue in close proximity to the parent trunk. (See Figs. I44–160.)
To inject these nerves in this position the mouth is held half-open,
the cheek drawn outward and upward, and the zygomatic process
reached with the finger; the needle is entered high up in the mucous
membrane about over the second molar, with its point directed up-
ward, backward, and inward, the syringe being held well away from
the bone; the solution is injected as the needle is advanced, with the

6O4 LOCAL ANESTHESIA
point hugging as closely as possible the convex surface of the tuber-
osity (Fig. 255) until its posterior surface is reached. From # to I
dram of a I to 2 per cent. Solution of a novocain-adrenalin Solution is
distributed along the track of the needle. Ten or fifteen minutes
may be required to attain the maximum anesthetic effect.
The lingual portion of the inferior maxilla is injected in a similar
manner, but where several teeth are to be anesthetized it will be
found best to block the inferior dental nerve at its entrance into the
dental canal, as described in the chapter on the Head.
When this form of anesthesia is resorted to an additional injection
will be necessary for the molars on their buccal surface, as this tissue
is supplied by the buccinator nerve. (See Fig. 162.)
A review of the appended table (pp. 606–608), taken from Fischer,
will be found useful, as indicating the points and methods of injection
in simple and complicated cases as well as the amount of anesthetic
Solution to be used.
Some years ago a pressure method of anesthesia for the painless
extirpation of pulps was introduced. The exact origin of this method
seems hard to trace; it was, however, early reported on by Dr. Kells,
of New Orleans, and H. H. Hill, of St. Louis (1899). For its success
it is necessary that the pulp be exposed, the essential feature being
the driving of the anesthetic under pressure into the root canal of the
tooth. It is carried out as follows: A Small piece of cotton (or spunk,
as originally recommended) is moistened with alcohol, and then
touched with the local anesthetic, preferred in powdered form, so that
a few Small crystals adhere to the cotton; this is placed in contact
with the exposed pulp; the rest of the cavity is then filled with or—
dinary red rubber (unvulcanized); light pressure is then applied with
a ball burnisher as large as can be fitted to the cavity; as the pain
ceases the pressure is increased until considerable force is exerted,
which is continued for a few minutes; this has the effect of driving the
anesthetic into the pulp canal. When the exposure of the pulp is
minute after the first application, the opening is enlarged and the
process repeated. When this has been properly carried out it should
permit the painless use of the broach.
It is said that when arsenic has been previously used the resulting
anesthesia is not usually as pronounced.
Cataphoresis has been used in dental Surgery, but is not very popu-
lar and requires much time. Other electric devices have been used,
but do not properly come within the scope of this book.
For regional methods of anesthesia applicable to more extensive
THE ORGANS OF SPECIAL SENSE WITH DENTAL ANESTHESIA 605
dental operations reference should be had to the chapter on the
Head, which describes the technic necessary for regional anesthesia
of the upper and lower jaws, the illustrations being particularly useful.
“Additional explanation of tables: The period of waiting in Cases
I to Io is about ten minutes; after injection in the inferior dental
foramen as in Nos. II to 16, twenty minutes. In Nos. I3 to 16 no
injection lingually is required. All combinations of anesthesia of several
teeth on one side can easily be calculated by applying to the first and
last tooth of the series to be anesthetized the technic specially indi-
cated for the same in the tables.
“If, for example, the right half of the upper jaw, from the canine
to the third molar, is to be anesthetized, an injection is made in the
canine fossa at the root apex of the canine; the needle is then advanced
along the periosteum to the root apex of the second bicuspid, injecting
altogether 2 c.c.; then I c.c. is injected at the maxillary tuberosity,
about Io drops in the posterior palatine foramen, and about o.25 c.c.
palatally, between the canine and first bicuspid.”
3.
TABLE A (CoPIED FROM FISCHER).
Teeth—I. Upper.
Technic of injection employed.
Mountings of
Quantity of solution.
(a) In simple cases. (b) In cases º periostitis, Syringe. In *::::: ºccal In Pºua
I. Central in- | Needle inserted at root center of lateral, Needle inserted at root centers of canine Hubs B or C. In cases. Of class.
cisors. and directed to root apex of central. and central of opposite side, whose root | Needle No. (a) o.5 c.c. (a) o. I c.c.
apices are infiltrated with solution. I7a. (b) I.O c.c. (b) o.3 c.c.
Palatally, injection at central. Palatally, injections at lateral and cen- || For conductive
- tral of opposite side, or conductive anesthesia,
anesthesia from infra-orbital fora- needle No.
men, and mucous anesthesia at Cen- I7C.
tral of opposite side, palatally.
2. Lateral in- || Needle inserted at root center of canine, Needle inserted back of root apex of As in I. (a) o.5 c.c. (a) o. I c.c.
cisors. and directed to root apex of lateral. canine, where solution is deposited; (b) I.o c.c. (b) o.3 c.c.
same procedure at root apex of
central.
Palatally, injection of lateral. Palatally, injection at lateral, or at cen-
tral and canine.
3. Canines. Needle inserted back of root apex of Conductive anesthesia from infra-orbital | (a) As in I. (a) o. I c.c. (a) o.5 c.c.
canine, where some solution is depos- foramen. (b) Long needle (b) o.5 c.c. (b) o.5 c.c.
ited, and directed toward canine. No. 17C.
Palatally, injection at the canine. Palatally, injection at canine, or first
bicuspid and lateral.
4. First bicus- | Needle inserted in center of canine, and | Conductive anesthesia from infra-orbital | (a) As in I. (a) I.o. c.c. (a) o.5 c.c.
pid. directed to root apex of first bicuspid. foramen, or injections at root apices of (b) As in 3. (b) I.5 c.c. (b) o.5 c.c.
canine and second bicuspid.
Palatally, injection at first bicuspid. Palatally, injection of first bicuspid, or
second bicuspid and canine.
5. Second bi- Needle inserted in center of first bicuspid Conductive anesthesia from infra-orbital (a) As in I. (a) 1.5 c.c. (a) o.50 c.c.
cuspid. and directed to root apex of second bi- foramen, and injection at maxillary (b) As in 3. (b) 2.0 c.c. (b) o.25 c.c.
cuspid.
Palatally, injection at second bicuspid.
tuberosity.
Palatally, injection at second bicuspid
and posterior palatine foramen.
3.
Injection at maxillary tuberosity and
infra-orbital foramen.
Palatally, injection at posterior palatine
foramen.
Palatally, injection at posterior palatine
foramen.
(a) and (b) Hub
B and needle
No. 17C; if de-
sirable in in-
jection a t
maxillary tu-
berosity, mid-
dle piece D.
As in 6.
As in 6.
(a) I.5 c.c.
(b) About Io
drops.
As in 6.
As in 6.
(a) o.25 c.c.
(b) About Io
drops.
As in 6.
As in 6.
Quantity of solution.
6. First molars.
7. Second mo-
lars.
8. Third molars.
Injection at maxillary tuberosity and
root center of first molar.
Palatally, injection at posterior palatine
foramen.
Injection at maxillary tuberosity and
root center of second molar.
Palatally, injection at posterior palatine
foramen.
Injection at maxillary tuberosity and
root center of third molar.
Palatally, injection at posterior palatine
foramen.
Injection at maxillary tuberosity and
infra-orbital foramen.
Palatally, injection at posterior palatine
foramen. -
Injection at maxillary tuberosity.
TABLE B (CoPIED FROM FISCHER).
Teeth—Lower.
Technic of injection employed.
(a) In simple cases.
(b) In cases complicated by periostitis,
Mountings of
syringe.
In labial or buccal
In palatal or lingual
parulis, etc. injections. injections.
9. Central in- | Needle inserted at root of center lateral, Needle inserted at reflection of mucous (a) Hub B and (a) o.6 c.c. (a) o.25 c.c.
cisors. and directed to root apex of central. membrane below central, and directed needle No. (b) I.o c.c. (b) o.25 c.c.
to mental fossa, where solution is de- I 7a. -
- posited. (b) Hub C and
Lingually, injection at central. Lingually, injection at lateral. needle No.
I7C.
Palatally, al-
ways middle
piece E and
needle No.
I7a.
Io. Lateral in- | Needle inserted at root of center canine, Needle inserted at reflection of mucous | (a) As in 9. (a) o.6 c.c. (a) 0.25 C.C.
cisors. and directed to lateral. - membrane below canine, and directed (b) As in 9. (b) I.O C.C. (b) o.25 c.c.
Lingually, injection at lateral.
to mental fossa, where solution is de-
posited.
Lingually, injection at canine.
3.
TABLE B (CoPIED FROM FISCHER)–(Continued).
Teeth—Lower.
Technic of injection employed.
(a) In simple cases.
(b) In cases complicated by periostitis,
parulis, etc.
Mountings of
Syringe.
Quantity of solution.
In labial or buccal
injections.
In palatal or lingual
injections.
II. Canines.
I2. First bicus-
pid.
Needle inserted at reflection of mucous
membrane below canine, and directed
to mental fossa, where solution is de-
posited.
Lingually, injection at canine of first
bicuspid, or conductive anesthesia
from mandibular foramen.
Needle inserted in gingival papilla of
canine, and directed horizontally to
first bicuspid.
Lingually, injection at first bicuspid, or
conductive anesthesia from mandibu-
lar foramen.
Needle inserted at reflection of mucous
membrane below canine, and directed
to mental fossa, where solution is de-
posited. Conductive anesthesia from
mandibular foramen.
Lingually, injection at first bicuspid.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of first bicuspid.
Lingually, injection at second bicuspid.
(a) and (b) Hub
C and needle
No. 17C.
Lingually, Hub
E and needle
No. 17a.
(a) Hub B and
needle No.
I7a.
(b) Hub B or C
and needle
No. 17C.
Lingually, mid-
dle piece E
and needle
No. 17a.
(a) and (b) Hub
C and needle
No. 17C.
(a) and (b) Hub
C and needle
No. 17c.
(a) and (b) Hub
C and needle
No. 17o.
(a) and (b) Hub
C and needle
No. 17C.
(a) I.o c.c.
(b) 2.0 c.c.
(a) I.o c.c.
(b) 2.5 c.c.
I3. Second bi-
cuspid.
14. First molars.
15. Second mo-
lars.
16. Third molars.
Conductive anesthesia from mandibular
foramen, and injection buccally at
second bicuspid.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of first molar.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of second molar.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of third molar.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of first bicuspid.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of second bicuspid.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of first molar.
Conductive anesthesia from mandibular
foramen, and injection buccally in
papilla of Second molar.
(a) I.5 c.c.
(b) 2.5 c.c.
(a) 2.5 c.c.
(b) 2.5 c.c.
(a) 2.5 c.c.
(b) 2.5 c.c.
(a) 2.5 c.c.
(b) 2.5 c.c.
(a) o.25 c.c.
(b) o.25 c.c.
(a) o.25 c.c.
(b) o.25 c.c.
3.
TABLE I (CoPIED FROM HARTEL)
SENSORY INNERVATION OF THE HEAD AND NECK WITH MUCOUS MEMBRANES AND MENINGES
Compiled from “Anatomies” -
Cranial or spinal nerve. Nerve. Principal branches. Territory of distribution.
A. SENSORY INNERVATION OF THE SKIN
I. Trigeminus Distribution
Lacrimal... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin on outer angles of lids. f head
tº Supra-orbital... . . . . . . . . . . . . . . . Upper lid, forehead, and vertex of head.
Vi Ophthalmic nerve. . . . . . . i. & E a tº e º is a s : * > * g g g g º gº e º a Supratrochlear... . . . . . . . . . . . . . . . Skin on inner angles of lids.
tº º e Ant. ethmoid (nasal nerve) . . . . . Tip of nose. -
Nasociliary. . . . . . . . . Infratrochlear... . . . . . . . . . . . . . . . Skin on inner angles of lids.
Temporal. . . . . . . . . . . . . . . . . . . . Anterior part of temple.
(Temporomalar... . . . . . . . . . . . . . Malar... . . . . . . . . . . . . . . . . . . . . . . Malar region.
Side of nose.
V, Maxillary nerve. . . . . . . . Infra-orbital... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lower lid.
Anterior part of cheek.
Upper lip.
Buccinator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin at angle of mouth.
Anterior part of ear.
Auriculotemporal... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . {:
Wa Mandibular nerve. . . . . . . - º
[Inf dental. . . . . . . . . . . . . . . . . . . Mental... . . . . . . . . . . . . . . . . . . . . . ë. 1p.
Spinal nerve and scheme of rami-
Cation. Nerve. Principal branches. Territory of distribution.
II. Anterior Branches of the Spinal Nerves (Area Cutanea Anterior)
(CI) -
C.. . . . :::::::::::::::. . . . Occipitalis minor... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Posterolateral region of head.
* * * * * : . . . . . . . . . . ; ; ; ; ; ' ' | U Auricularis magnus... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ear, temple, and side of face.
Qs. ; ; ; ; ; ; . . . . . . . . .'; ; ; ; ; , Superficialis colli..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anterior region of the neck.
C. . . . . . . . . . . . . . . ." . . . . . . . . Supraclavicular... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Upper part of thorax and shoulder.
TABLE I (Continued)
§
Spinal nerve # ...heme of rami- Nerve. Principal branches. Territory of distribution.
III. Dorsal Branches of the Spinal Nerves (Area Cutanea Posterior)
(CI) e
C. . . . . . . . . . . . . . . . . . . . . . . Lateral branches. . . . . . . . . . . . . . . Occipitalis major and tertius. . . . | Median posterior region of head.
Ca. . . . . . . . . . . . . . . . . . . . . . . & C “ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Posterior region of neck.
C. . . . . . . . . . . . . . . . . . . . . . . . & 4 ( &
o: & 4 6 &
ö. . . . . . . . . . . . . . . . . . . . . . . ( { & 4
Č. . . . . . . . . . . . . . . . . . . . . . . . {{
Cs. . . . . . . . . . . . . . . . . . . . . . . ( & & & b-
2
P
b-
Cranial nerve. Nerve. Principal branches. Territory of distribution. %
* br;
4;
† B. SENSORY INNERVATION OF THE MUCOUS MEMBRANE É
- I. Conjunctiva and Bulbus Oculi #
Lacrimal... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outer part upper and lower lids (Zander).
Supra-orbital l e
V1 Ophthalmic. . . . . . . . . . . . Frontal... . . . . . . . . . . . . . . . . . . . . Supratrochlear j : ' ' ' ' ' ' ' ' ' ' ' ' Inner part upper lid.
e Լ & Infratrochlear. . . . . . . . . . . . . . . . Inner part lower lid and tear sac.
NaSociliary. . . . . . . . . . . . . . . . . . Ganglionic and ciliary. . . . . . . . . Cornea, conjunctiva, bulb.
V, Maxillar Infra-orbital... . . . . . . . . . . . . . . . Palpebral... . . . . . . . . . . . . . . . . . . . Lower and part of upper lid (Zander).
2 Y . . . . . . . . . . . . . . Temporomalar... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lateral part lower lid.
II. Nose and Accessory Sinuses.
a. Nasal Fossa
Vi Ophthalmic. . . . . . . . . . . . Nasociliary. . . . . . . . . . . . . . . . . . . . Ant. ethmoid (ant. nasal)... . . . . . . Anterior upper part nasal fossa.
º Sphenopalatine... . . . . . . . * } o e
V, Maxillary. . . . . . . . . . . . . . Sphenopalatine ganglion. ſ ' ' ' ' Post, nasal (sup. and inf.). . . . . . . Remainder of nasal fossa.
#
5
Sphenoid sinus.
Posterior ethmoid cells.
Anterior ethmoid cells.
Frontal sinus.
Antrum of Highmore.
Upper teeth and gums on buccal side.
Mucous membrane of the upper lip.
Palatine tooth, periosteum, gums.
Hard and soft palate.
Lower teeth and gums.
Mucous membrane, lower lip.
Lingual gum anterior teeth (Bünte and Moral).
Tongue to foramen cecum.
Mucous membrane, cheek.
Region Eustachian tube.
V, Ophthalmic. . . . . . . . . . . .
V2 Maxillary. . . . . . . . . . . . . .
V, Maxillary. . . . . ". . . . . . . . .
Va Mandibular. . . . . . . . . . . .
V2 Maxillary. . . . . . . . . . . . . .
Va Mandibular. . . . . . . . . . . .
IX Glossopharyngeal . . . . . . .
Sphenopalatine. . . . . . . . . . . . . . .
Infra-orbital... . . . . . . . . . . . . . . . .
| Infra-orbital... . . . . . . . . . . . . . . .
Sphenopalatine ganglion. . . . . . .
(Inf. alveolar... . . . . . . . . . . . . . . .
Lingual... . . . . . . . . . . . . . . . . . . . .
Buccinator... . . . . . . . . . . . . . . . . .
Sphenopalatine ganglion... . . . . . .
Lingual. . . . . . . . . . . . . . . . . . . . . . .
* g a sº e º e s ∈ sº º g : « g º e ºs e s tº # e. e. e. e. e. e º e
b. Accessory Sinuses
{. ethmoid. . . . . . . . . . . . . . . .
Ant. ethmoid. . . . . . . . . . . . . . . .
Nasal branches (Testut). . . . . . . .
Alveolar superior (post. med.
and ant). . . . . . . . . . . . . . . . . . . .
III. Mouth
Sup. alveolar. . . . . . . . . . . . . . . . .
Sup. labial branches.. . . . . . . . . .
Nasopalatine. . . . . . . . . . . . . . . . .
Palatine. . . . . . . . . . . . . . . . . . . . .
Dental... . . . . . . . . . . . . . . . . . . . . .
Mental. . . . . . . . . . . . . . . . . . . . . .
Sublingual. . . . . . . . . . . . . . . . . . .
| Lingual branches. . . . . . . . . . . . .
Isthmi fauc. branches.. . . . . . . .
IV. Pharyna and Larynx
Pharyngeal (Boek). . . . . . . . . . . . .
Branches to isthmi fauc.. . . . . .
Pharyngeal tonsil, lingual
branches. . . . . . . . . . . . . . . . . .
Pharyngeal. . . . . . . . . . . . . . . . . . . .
| Internal. . . . . . . . . . . . . . . . . . . . .
External... . . . . . . . . . . . . . . . . . . .
. | Part of tonsil.
| Part of tonsil.
Pharynx (vagus).
| Tonsil, pillars of tonsil.
Base of tongue behind foramen cecum.
Pharynx.
Base of tongue near epiglottis.
Entrance of larynx to rima glottis.
Mucous membrane of larynx below rima glotis and
ventricle of Morgagni (Testut).
3.
TABLE I (Continued)
Sensory nerve ending.
Territory of distribution.
Cranial or spinal nerve.
Nerve.
V, Maxillary. . . . . . . . . . . . . .
Va Mandibular. . . . . . . . . . . .
Sphenopalatine ganglion... . . .
| Auriculotemporal. . . . . . . . . . . . .
Spinal recurrent . . . . . . .
V. Mucous Membrane of Ear
. . Pharyngeal. . . . . . . • - - - - - - - - - - - -
e e º e s ∈ e º e º s = e tº e < * * * * g e < e < e s ∈ E =
* * * * * e s : s = e g º ºr g g º ºs e º e s sº e º e s s a e
Tube (glossopharyngeal).
External auditory passage, outer surface of tympa-
num (vagus and second cervical).
Mastoid cells (glossopharyngeal).
Tube.
Tympanic cavity.
IX Glossopharyngeal . . . . . . . Tympanic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inner surface of tympanum.
Mastoid cells.
* tº External auditory passage.
X Vagus. . . . . . . . . . . . . . . . . Auricularis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outer surface tympanum (trigem. and sec. cervical).
C, Anterior branch. . . . . . . . . Auricularis magnus.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External auditory passage (trigeminus and vagus).
Cranial nerve. Nerve. Terminal nerve. . Territory of distribution.
C. SENSORY INNERVATION OF DURA MATER
V. . . . . . . . . . . . . . . . . . . . . . . . Ophthalmic... . . . . . . . . . . . . . . . . . Tentorial (origin within the skull). Tentorium cerebelli.
V. . . . . . . . . . . . . . . . . . . . . . . . Maxillary. . . . . . . . . . . . . . . . . . . . . Middle meningeal (origin within Dura, anterior and middle cranial fossa.
the skull).
V. . . . . . . . . . . . . . . . . . . . . . . . Mandibular... . . . . . . . . . . . . . . . . . Spinosus (origin without the Dura, middle cranial fossa (sphenoid sinuses and mas-
skull). toid cells).
X Vagus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meningeal (origin without the Dura, posterior cranial fossa around jugular foramen.
skull from the jugular ganglion).
XII. Hypoglossal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occipital (origin in hypoglossal. Dura, posterior cranial fossa around foramen magnum.
canal; sensory branch originates
probably from the lingual V3).

§
TABLE II (CoPIED FROM HARTEL)
COMPILATION OF INVESTIGATIONS ON SKULL
No. * in igation. in igation. Number of Nº. of indi:
Subject of investigation Result of investigation skulls examined. .**
The total number of skulls examined was 69, of which 15 were complete, 4 half skulls; the remainder were bases with
or without vertex and inferior maxilla. 69
Ten isolated Sphenoid bones were examined, as well as a number of other isolated bones. IO
I Length of foramen ovale. inimum . . . . . . . . . . . . . . . . . . . . . . . . 5 mm 62 II6
Maximum. . . . . . . . . . . . . . . . . . . . . . . . II { {
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 “
2 | Width of foramen ovale. Minimum . . . . . . . . . . . . . . . . . . . . . . . . 2 In Il Ö2 II.4.
Maximum . . . . . . . . . . . . . . . . . . . . . . . . 7% “
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 3.7 “
3 || Varieties of foramen ovale. (See Observation to No. Io.) | A width of 3 mm., unfavorable for the injection, occurred
II times, 8%. 7I I34.
Impossible for injection, due to bony variations (ossified
lig. pterygospinosus bridging the foramen), occurred
once. The smallest foramen measured 5X2; the largest,
1 IX5 mm. Circular or oblique forms were observed 4
times.
Ossification of the lig. pterygospinosum 9 times in 5 skulls.
Union of foramen ovale and for. Spinosum 4 times in 3
skulls. .
Union of for. ovale with for. lacerum 3 times on 3 skulls.
4 | Distance of for. Spinosum, caroticum, and jugulare from For. spin., minimum. . . . . . . . . . . . . . . O IOlſſl. I5 24
posterior edge of for. ovale. Maximum . . . . . . . . . . . . . . . . . . 6 ( &
Average. . . . . . . . . . . . . . . . . . . . . 2.3 “
For. carot., minimum. . . . . . . . . . . . . . 8 mm I8 3I
Maximum . . . . . . . . . . . . . . . . . . I7 C &
Average. . . . . . . . . . . . . . . . . . . . . 12.7 “
For. jug., minimum . . . . . . . . . . . . . . . I5 mm. I8 3 I
Maximum . . . . . . . . . . . . . . . . . . . 28 ( &
Average. . . . . . . . . . . . . . . . . . . . . 2O
É
TABLE II (Continued)
No. Subject of investigation. Result of investigation. riºd.
5 Relation of pterygoid process to for. ovale: a = width of (a) Minimum . . . . . . . . . . . . . . . . . . . . . 6 mm I8
upper part lamina externa; b = distance of anterior edge Maximum. . . . . . . . . . . . . . . . . . . . . I6 ( &
for. ovale from ant. edge lamina externa; y = b – a in- Average. . . . . . . . . . . . . . . . . . . . . . . I2.3 “
dicates the dangerous interval along which the needle (b) Minimum . . . . . . . . . . . . . . . . . . . . . 9 mm.
passes between the pterygoid process and the for. ovale. Maximum . . . . . . . . . . . . . . . . . . . . . I8 & 4
Average. . . . . . . . . . . . . . . . . . . . . . . 14.2 “
(y) Minimum. . . . . . . . . . . . . . . . . . . . . – 2 mm.
Maximum . . . . . . . . . . . . . . . . . . . . . +8 “
Average. . . . . . . . . . . . . . . . . . . . . . . +2 “
The smaller the y, the surer the injection. Negative value for y was found Io times, value greater
g than 4 mm. twice.
6 | Distance of for. ovale (lower edge) from upper edge of Minimum . . . . . . . . . . . . . . . . . . . . . . . . I4 mm 58
pyramid of petrous bone to impressio trigemini (= in- Maximum. . . . . . . . . . . . . . . . . . . . . . . . 23 “
tracranial distance of route to gasserian ganglion). Average. . . . . . . . . . . . . . . . . . . . . . . . . . I9 “ i
7 | Projection of “trigeminal axis” on the alveolar process of Inclination of the axis overflat 7 times = 6.1%. | 6 I
upper jaw. “Overflat” means cutting the alveolar Inclination of the axis flat 32 times = 28%.
process in front of the zygomatic process; “flat,” under |Inclination of the axis medium steep 44 times = 38.6%.
the zygomatic process; “medium,” between the zygo-|Inclination of the axis steep 27 times = 23.8%.
matic process and post. edge of alveolar process; “steep,” Inclination of the axis oversteep 4 times = 3.5%.
on the posterior edge; “oversteep,” beyond the post. In about 90% the axis to the ganglion meets the upper jaw
edge of alveolar process. - in the region of the third molar tooth.
8 || Distance of the ant. edge of ramus of lower jaw to tuber- Minimum . . . . . . . . . . . . . . . . . . . . . . . . 8 mm. I8
maxillare. Maximum. . . . . . . . . . . . . . . . . . . . . . . . 18% “
Average. . . . . . . . . . . . . . . . . . . . . . . . . . I 2.8 “
The distance was less than 12 mm. 9 times = 23.7%; 12 mm. and over 20 times = 76.3%, or in about one-fourth of the
cases is it impossible to feel the planum infratemporale from the mouth.
9 || Width fossa pterygopalatine (greatest diameter of en- Minimum . . . . . . . . . . . . . . . . . . . . . . . . 3 mm. 39
trance). Maximum . . . . . . . . . . . . . . . . . . . . . . . . . II iſ &
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 “
Narrow fossa with a width of 3 mm. was found in about
40% of cases.
Number of indi-
vidual meas-
Ulreſſ, entS.
I IO
II4
38
75
IO
II
I3
I4
I5
I6
I7
I8
Varieties of fossa pterygopalatine. Observation: since the
statistics in large part deal with selected material, the
figures of the frequency of varieties must be accepted
with caution.
Where a horizontally introduced needle, above zygomatic
arch, meets the fossa pterygopalatine (Offerhaus
method). The more pronounced the Crista infratem-
poralis and the tuberculum sphenoidale, the deeper will
be the fossa.
Injection of for. rotundum from the fossa pterygopalatina
by the Braun method.
Tuberculum sphenoidale strongly developed (pyramidal,
flat, and pointed forms), 62 times.
Strongly developed marginal ridge (anterior edge lamina
externa pterygoid proc.), 36 times; ant. pterygoid spine,
9 times.
Fossa developed by the sharply projecting pneumatized
walls of neighboring sinuses (especially proc. orbitalis os.
palatini), 9 times.
(a) In upper part fossa Io times, 12%.
(b) In for. Sphenopalatine 46 times, 55%. .
(c) Below for. Sphenopalatine 20 times, 24%.
(d) Introduction of needle by this route impossible 8 times,
| QYO. *
Injection possible 38 times, 33%.
Injection impossible” 77 times, 67%.
| - -
| * The fossa in these cases was reached and the point of
the needle was near the for. rotundum.
Position of injection to reach the fossa pterygopalatina by Point of injection in front of sutura zygomatico maxillaris,
this method. (The more pronounced the tubermaxillare,
the further behind should the needle be entered.)
Distance of for. rotundum from lower border of zygoma at
zygomaticomaxillaris suture (Braun method). -
Condition of route to for. ethmoid post. (Inner smooth
plane of orbit.)
Condition of lateral smooth plane of orbit (route to oph-
thalmic and lacrimal nerve).
15 skulls, Io96.
Under the suture, 26 skulls, 52%. , to 1% cm. behind the
suture in 19 skulls, 38%.
Minimum . . . . . . . . . . . . . . . . . . . . . . . . 45 mm.
Maximum . . . . . . . . . . . . . . . . . . . . . . . . 57 “
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 5o “
Route smooth, 42 skulls, 80%.
Route slightly concave, 6 skulls, 12%.
Route slightly convex, 4 skulls, 8%.
(a) Smooth or slightly concave (o.2 mm.), 18 skulls, 13%.
(b) Concave (3.4 mm.), 38 skulls, 60%.
(c) Strongly concave (5 mm.), 6 skulls, Io9%.
The concavity was in about half the cases (35) equal above and below, in ; above (13) and under (14) very pronounced;
in 2 cases there existed a biconcave surface through protrusions of the great wing of the sphenoid.
Condition of inferior smooth plane of orbit (route for
orbital injection of maxillary nerve).
Resistance encountered by needle behind post, ethmoid
for, in median orbital injection (marked development of
Sphenoid sinus).
Smooth in 6 skulls, 50%.
Concave (3 mm.), 3 skulls, 25%.
Strongly concave, 3 skulls, 25%.
Needle met resistance in 12 skulls, 50%.
No resistance in I2 skulls, 50%.
Óo
46
Ö2
. 50
I 2
24
II6
84
II 5
I5
É
TABLE II (Continued)
No. Subject of investigation. Result of investigation. sº i. d. Nº.
urementS.
I9 | Distance of ant. ethmoid foramina from inner edge of orbit Minimum . . . . . . . . . . . . . . . . . . . . . . . . I5 mm I3 26
at height of injection. Maximum. . . . . . . . . . . . . . . . . . . . . . . . 22 ( (
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 18.5 “
20 | Distance of post. ethmoid for. from similar point. Minimum . . . . . . . . . . . . . . . . . . . . . . . . 29 mm 6I II9
Maximum. . . . . . . . . . . . . . . . . . . . . . . . 42 { {
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 34.o “
21 | Distance of optic foramen from similar point. Minimum. . . . . . . . . . . . . . . . . . . . . . . . 33 mm.* 28 56
Maximum . . . . . . . . . . . . . . . . . . . . . . . . 47 & &
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 4o.8 “
* The minimum, 33 mm., was observed only once; the
next highest minimum was 37.
22 | Resistance encountered by needle in lateral orbital injec- || Met resistance IoS times, 86%. 63 I 22
tion on orbital roof (narrow superior fissure), no resist- | No resistance 17 times, 14%.
ance (wide sup. fis.).
23 | Distance of outer edge of fis. orbitalis sup. from outer edge Minimum . . . . . . . . . . . . . . . . . . . . . . . . 27 mm 59 II 2
of orbit at height of frontomalar suture. Maximum. . . . . . . . . . . . . . . . . . . . . . . . 4O & 4
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 33.5 “
24 || Injection of for. rotundum by orbital route (possible with (a) Possible II 2 times, 89%. 68 I 26
wide fissure, impossible with narrow or tortuous fissure). (b) Impossible I4 times, 11%.
25 | Distance of for. rotundum from outer lower edge of orbital Minimum. . . . . . . . . . . . . . . . . . . . . . . . 30 mm 63 II.8
margin. Maximum. . . . . . . . . . . . . . . . . . . . . . . . 5 I { {
Average. . . . . . . . . . . . . . . . . . . . . . . . . . 45.4
I ND EX
ABDOMEN, 295
Abdominal contents, experiments
under local anesthetics, 306
muscles, reflex rigidity of, 303
operations, 338
organs, sensibility of, 296, 305, 333
wall, anesthetizing, 336
Absorption by nerve-trunks, 162
Acids and alkalis, effects of, on Osmosis, 49
Adenoids, 596
Adrenalin, 132
in eye, 583
in hemorrhoids, 137
in poisoning from local anesthetics, 128
in snake-bite, 136
in spinal analgesia, 432
in splenic enlargement, 137
in urethral stricture, I37
in uterine inertia, 136
physiologic action, I 35
toxicity, 138
use of, I4o, I5o
Air, experimental use of, when injected, 66
Akoin, 81
Alcohol as local anesthetic, 63–68
experimental use of, 69
injection of internal laryngeal nerve in tu-
bercular laryngitis, 271
of nerves, 527, 573
injections for neuralgia, 68
Alexander's operation, 401
route to third division of fifth nerve, 529
Alkalis, effects of, on osmosis, 49
Allen's method of anesthetizing abdominal
wall, 336
Alypin, 83
nitrate, 85
Ammonia in poisoning from local anesthet-
ics, I27
Amyl nitrite in poisoning from local anes-
thetics, 127
Anal canal, sensibility of, 332
Analgesia, 28
with,
Andolin, 71
Anesin (aneson), 89
Anesthesia, 28
dolorosa, 63–65
Anesthesin, 93
in tubercular laryngitis, 94
Anesthetic effects of carbonic acid gas, 19
of pressure, 58
local, 67
Animal experiments, abdominal, 306
intra-arterial, 20I
Anoci-association, 194
Anodyne applications at the siege of Troy,
I7
Anorectal region, 384
Anterior crural nerve, 244
thoracic nerves, 283
blocking, 285
tibial nerve, 246
Antidolorin, 6o
Antipyrin in combination with cocain, I 26
local anesthetic action of, 70
Antrum of Highmore, operations upon, 596
Appendectomy, 341
Applicators, proper use of, 592
Arm, anesthetizing, 216
Armamentarium, 164
Arterenol, 132-134
Arterial anesthesia, 200
Arteries, danger of wounding, T 74
sensibility of, 37, 328
Artery, common carotid, ligation of, 265
external carotid, ligation of, 266
internal maxillary, 557
middle meningeal, 557
of sleep, 18
Articular tubercle, 533, 565
Auricle, anesthetizing, 584
BACK, 291
nerves of, 291
blocking, 293
Barker’s solution of eucain, 8o
617
618
INDEX
Bartholin's glands, removal of, 399
Baudoin and Levy orbital injection, ophthal-
mic nerve, 471, 5oo
Bladder, anesthesia of, 379–381
nerve-supply of, 367
sensibility of, 378
Bone, method of chiselling, 588
sensibility of, 37, 213
Brachial plexus, 215
anesthetizing, 215
paraneural injection of, above clavicle,
2I8
within axilla, 222
Brain, operations upon, 481
sensibility of, 26, 48o
Braun, lateral orbital injection of, 507
route to third division of fifth nerve, 562
method of anesthetizing abdominal wall,
336
solution of eucain, 8o, I57
of novocain, 157
Breast, operations on, 289
Bromids after rectal operations, 393
before operations, 591
local anesthetic action of, 70
Brucin, local anesthetic action of, 70
Bubo, 248
Burgi’s law, 185
CAMPHOR, oil of, in poisoning from local
anesthetics, I31
Cancerous growths, method of dealing with,
I78
Carbolic acid, 67, 393
Carbon dioxid, 63
Carbuncles, 178, 29I
Carotid canal, 532
Cartilage, sensibility of, 37
Caruncles, removal of, 399
Castration, 375
Cataphoresis, 377
first use of, 20
Cataract, removal of, 581
Cathelin, epidural injection of, 453
. Cauda equina, 406
Cavernous sinus, 555
Cavum Meckeli, 553, 554
Cerebrospinal fluid, movements of, 407
specific gravity of, 412
Cervix, uterine, anesthetizing, 398
sensibility of, 395
Cesarean Section, 403
Chalazion, 58o -
Chancroids, 377
Chest wall, anterior, anesthetizing, 285
Chloral hydrate after rectal operations, 393
local anesthetic action of, 70
Chloretone, 89
in treatment of gastric diseases, 9o
Chloroform in poisoning from local anes-
thetics, 127
local anesthetic action of, 20, 68
mortality from, 147
Cinnamyl-Cocain, 131
Circular anesthesia, 177
Circumcision, 370
Cisterna terminalis, 407
Coca leaves, use of, 22
plant, early history of, 21
Cocain, 73
aluminum citrate, 73
borate, 73
cantharidate, 73
carbolate, 73
deaths from, 123
effects on cornea, 579
first use of, anesthetic action, 20, 72
general anesthesia from, 2Io, 306, 307
hydrochlorate, 73
intra-arterial lethal dose, 124
intravenous lethal dose, 124
lactate, 73
maximum dose used, I25
mydriatic action of, 78
nitrate, 73
prenate, 68
phosphate, 74
physiologic action of, 74
poisoning, 12I
saccharate, 74
salicylate, 74
sedative effects of, following general anes-
thesia, 306–3C9
Stearate, 74
subcutaneous lethal dose, 124
Sulphate, 73
tests for, 74
Codrenin, 71
Cold, 6d, 173, 238
first use of, for anesthesia, 60
solutions, anesthesia from, 63
Colic, intestinal, pain of, 296, 3oo
Colostomy, 341
Colporrhaphy, anterior, 397
Combined methods of anesthesia, 187
Common carotid artery, ligation of, 265
INDEX
619
Concentrated solutions, action of, 161
use of, with Swab, 591
Constrictors, first use of, 19
practical use of, I 24, 141, 151, 178, 237
Contra-indications for local anesthesia, 191
Conus terminale, 406
Cyclitis, 582
Cycloform, 71
Cysterna pontis, 553, 554
Cystotomy, suprapubic, 379
DENTAL anesthesia, 598
syringe and needles, 599
table, Fischer, 606
Diffusion, 44
Digitalis group, local anesthetic action of, 71
in poisoning from local anesthetics, 127
Direct anesthesia, 207
Dührssen-Bumm operation, 399
Dura mater, sensibility of, 479
EAR, 584
external, anesthetizing, 584
Elbow, blocking nerve-trunks at, 226
paraneural injections at, 229
Elbow-joint, nerve-supply of, 214
Electric and nerve currents, 4o
Eminentia articularis, 532, 565
Epidural injections of Cathelin, 453
Epinephrin, 132, 134
Epirenin, 132
Epispadias, 374
Erythroxylin, 20, 74
Esophagus, sensibility of, 332
Ether, hydrochloric, 6o
in poisoning from local anesthetics, 127
mortality from, 147
Sprays, first use of, 19, 6o
Ethmoid foramina, 506
Ethyl chlorid, 6o
Eucain, 78
Barker's solution, 8o
Braun solution, 8o
hydrochlorate, 79
lactate, 79
solubility of, 79
Eudrenal, 132
Eusemin, 71
Eustachian canal, 532
Exophthalmic goiter, 274
External auditory canal, anesthetizing, 584
Carotids, ligation of, 266
cutaneous nerve, lower extremity, 243
External cutaneous nerve, upper extremity,
224
laryngeal nerve, 264
plantar nerve, 246
popliteal nerve, 246
Spermatic nerve, 348
Eye, 579
enucleation, 583
paralysis of muscles of, following spinal
analgesia, 447
Eyelids, operations upon, 58o
FACE, anesthetizing, 487
Fat, sensibility of, 36
Faucial tonsil, 596
Femoral hernia, 358
Femur, nerve-supply of, 214
operations upon, 252
Fibroids of uterus, 402
Fibula, nerve-supply of, 214
Fifth nerve, 471
Filum terminale, 406
Fingers and hand, 231
Fischer's dental anesthetic, 599
Fissure, rectal, 391
Fistula in ano, 396
Foot, sole of, 256
Foramen Civinini, 535
lacerum anterius, 498
medium, 531
ovale, 530-533
axial injection of, 523
rotundum, 509, 530
axial injection of, 507
Spinosum, 531
Forearm, anesthetizing, 226
paraneural injection of, 231
Fractures, anesthetizing, 214
Freezing, early use of, with ice and snow, Io
Frontal nerve, injection of, 5o'7
sinus, operations upon, 508
GALL-BLADDER, operations upon, 341
sensibility of, 297
Gartier's test for cocain, 74
Gasserian ganglion, 554
complications following injection of,
554, 576
injection of, 528
Härtel route, 533, 57.1
Gastro-intestinal tract, sensibility of, 307
Gelatin, use of, in paravertebral injections,
459
62o
INDEX
General anesthesia from cocain, 306, 307
from intravenous injection of local
anesthetics, 2Io
Genitocrural nerve, 348
Genito-urinary Organs, 364
Glaucoma, 582
Goiter, 272
exophthalmic, 274
simple colloid, 273
Great sciatic nerve, 245
Gynecologic operations, 393
spinal analgesia in, 434
HACKENBUCH method, 177
Hand, 231
Hard palate, anesthetizing, 526
Harris injection of Gasserian ganglion, 528
Härtel injection of Gasserian ganglion, 533
Hemorrhage, control of, 181
Hemorrhoids, 391
Hemostasis, I42, 181
Hepatotomy, transthoracic, 287
Hernia, 346 -
femoral, 358
inguinal, 347
postoperative, 362
strangulated, 357
umbilical, 360
ventral, 363
Hip and thigh, 25o
Holocain, 81
antiseptic action, 82
Homarenon, I32, I 34, I44
Humerus, nerve-supply of, 2I4
Hydrocele, 375
Hydrophilic colloids, 48
Hyperthyroidism, ligation of thyroid ves-
sels, 276
Hypertonic solutions, 45
Hypodermic syringe, 165
dental, 599
history of, 182
Hypospadias, 374
Hypotonic solutions, 45
Hysterectomy, 393
Hysterotomy, anterior, 399
ILEUS, pain of, 3oo
Iliohypogastric nerve, 348
Ilio-inguinal nerve, 348
Indications for local anesthesia, 191
Indirect anesthesia, 207
Inferior dental canal, 516
Inferior dental nerve, injection at foram-
ina, 519
laryngeal nerve, 265
maxilla, 515
anesthetizing, 488
pudendal nerve, 366
method of blocking, 368
Infra-orbital foramina, 484, 486
nerve blocking, 485
region, operations upon, 489
Inguinal adenitis, 248
hernia, 347
region, nerve-supply, 243
Intercostal nerves, 281
blocking, 284
neuralgia, 494
Internal carotids, ligation of, 266
cutaneous nerve, lower external, 244
upper external, 224
jugular vein, 266
laryngeal nerve, alcohol injection of, 271
maxillary artery, 557
popliteal nerve, 245
Saphenous nerve, 245
Intestinal adhesions, pain from, 328
colic, pain of, 296, 3oo
Intestines, effect of spinal analgesia upon,
422
inhibition of sensibility produced by lapa-
rotomy, 325
sensibility of, 297, 307
Small operations upon, 342
Intra-arterial anesthesia, 200
Intracranial operations, 481
Intraneural anesthesia, I 75
Intravenous anesthesia, 206
Iris, operations upon, 581
Isatropylcocain, I31
Ischiorectal abscess, 391
Isotonic solutions, 45
Joints, method of anesthetizing interior of,
2I4
Jonnesco method of spinal analgesia, 450
Jugular fossa, 532
KELENE, 6o
Kidney, effects of spinal analgesia upon, 443
sensibility of, 317
Kiliani route to third division of fifth nerve,
529
Killian regional anesthesia of nasal Septum,
593
INDEX
62I
Knee-joint, 252
disarticulation at, 25o
nerve-supply of, 214
operations upon, 252
Koller's announcement to Ophthalmologic
Congress, 1884, 2I
early experiments, 21
Kulenkampff method of blocking brachial
plexus, 220
LACRIMAL nerve, 472
injecting, 507
Laryngectomy, 268
Laryngitis, tubercular, anesthesin in, 94
Larynx and trachea, 268
innervation of, 264
operations within, 597
Leg, 254
Lesser internal cutaneous nerve, 224
Levy and Baudoin method of injecting
ophthalmic nerve, 471, 5oo
Ligament, Civinini spina pterygospinosum,
535
denticulatum, 407
Ligation of carotid vessels, 265
of thyroid vessels, 276
Light, vibrations to produce, 41
Linea interzygomatica, 565
Lingual tonsil, 596
Lipectomy, 343
Lips, anesthetizing, 487
Liver abscess, 287, 342
Sensibility of, 296, 317
Llipta, 24
Local anesthetics, 67
comparative action of, 96
standards for, 71
toxicity of, in intraperitoneal injection,
97, IOI
in intravenous injection, 96, Ioo
applications of ancient Egyptians, 18
Long saphenous nerve, 245
paraneural injection of, 254
Löwenstein anesthesia of eye, 584
Lower extremity, 242
nerve-supply, 243
MACLAGAN test for cocain, 74
Magnesium salts, 119
intraspinal use, II9, 442
intravenous use, 119
Malignant disease of rectum, 391
growths, method of dealing with, 178
Mandibular foramen, 516
Mandragora atropa, 18, 19
Marrow, sensibility of, 37
Mastoid operations, 586
Matas axial injection of second division of
fifth nerve, 507
infiltrator, 176
Maxillary nerve, Matas axial injection of,
507
Meatotomy, 372
Median nerve, 224
paraneural injection of, 232
Meltzer-Auer intratracheal intubation
poisoning, 131
Meningismus following spinal analgesia, 438
Mental foramina, 484, 487
paraneural injections of, 486
Methoxycaffein, 68
Methyl chlorid, 61
iodid, 6o
oxid, 6o
Methylil, 61
Middle cutaneous nerve, 244
fossa of skull, 553
meningeal artery, 557
Military surgery, spinal analgesia in, 435
Modalities of sensory nerves, 26
Morphin and scopolamin, 183
in spinal analgesia, 423
in poisoning from cocain, 129
in Schleich solution, 155
local anesthetic action of, 20, 70
Morphin-cocain-ether anesthesia, 187
in
| Mouth, roof of, anesthesia of, 526
Mucous membranes, sensibility of, 37, 331
Musculocutaneous nerve, lower extremity,
246
upper extremity, 224
Musculospiral nerve, 225
NARCOTICs, reference to, in Homer's Odys-
sey, I 7
Nasal nerve, 472
intra-orbital injection of, 506
septum, operations upon, 592
Nasofrontal duct, 596
Nasopharynx, 596
Neck, 261
nerves of, 261
paraneural injection of, 263
Needles and syringes, 165
for deep cranial injections, 529
orbital injections, 514
622
INDEX
Needles and syringes for dental use, 599
for spinal analgesia, 427
Nerves, alcoholic injection of, 527
anterior crural, 244
thoracic, 283
blocking, 285
tibial, 246
auricularis magnus, to anesthetize, 477
auriculotemporal, 474 -
blocking of, I51, 215, 251
function of, vibratory theory of, 4o
brachial plexus, 215
blocking, 218, 220
external cutaneous, lower extremity, 243
upper extremity, 224
laryngeal, 264
plantar, 246
popliteal, 246
spermatic, 348
fifth, 471
injecting principal branches of, 485,
507, 519, 528, 533, 562, 563, 565
frontal, 472
intra-orbital injection, 507
genitocrural, 348
iliohypogastric, 348
ilio-inguinal, 348
inferior dental, 475
injecting at foramen, 519
hemorrhoidal, 364
laryngeal, 265
maxillary, 474
pudendal, 366
infra-orbital, blocking, 485
intercostal, 281
blocking, 284
internal cutaneous, lower extremity, 244
upper extremity, 224
popliteal, 245
Saphenous, 245
lacrimal, 472
intra-orbital, injection of, 507
lesser internal cutaneous, 224
lingual, 475
median, 224
method of injecting, I51, 216, 251
middle cutaneous, 224
musculocutaneous, lower extremity, 246
upper extremity, 224
musculospiral, 225
nasal, 472
nasopalatine, 474
obturator, 244
Nerves, occipitalis, major and minor, to
anesthetize, 477
of back, 291
blocking, 292
ophthalmic, 471, 5oo
palatine, 474
peroneal, 246
phrenic, 296
posterior tibial, 245
pudic, 364
method of blocking, 367
radial, 226
Sciatic, 245
sensations of, 26
superior dental, 474
maxillary, 472
supraclavicular, 283
blocking, 285
supra-orbital, 472
blocking, 475
supratrochlear, 472
blocking, 475
sympathetic, sensibility of, 329
temporomalar, 473
thorax, 281 -
ulnar, 225
Neumann method of anesthetizing mastoid,
586
Neuralgia, alcoholic injections in, 527
relief of, following cocain injections, 494
Nirvanin, 93
Nitroglycerin in local anesthetic mixtures,
I 26
Nitrous oxid in poisoning from local anes-
thetics, 127
Normal salt solution in poisoning from local
anesthetics, 129
Nose and throat, 588
to anesthetize, 487
Novocain, author’s solutions of, 158
Braun's solutions of, 157
clinical experiments with, 87
hydrochlorid, 85
maximum dose used, 125
nitrate, 88
OBERST method of anesthetizing penis, 369
Obstetrics, spinal analgesia in, 434
Obturator nerve, 244
Occipital region, operations upon, 484
Ocular palsies following spinal analgesia, 447
Offerhaus buccal route to mandibular
nerve, 528
INDEX
623
Offerhaus lateral route to mandibular
nerve, 563
to maxillary nerve, 565
Oily solutions of local anesthetics, 164
Omentum, sensibility of, 37
Ophthalmic nerve, 471, 5oo
injecting, 5oo
Optic foramen, 502
Orbits, 496
horizontal planes of, 503
lateral routes of injecting, 507
median routes of injecting, 506
routes of injecting, complications, 506
Orchidectomy, 375
Orthoform, 91
Osmosis, 44
Ostwalt buccal route for injecting third
division of fifth nerve, 528
Ovarian cysts, 402
PACINIAN corpuscles, 36
Pain centers, 26
definition, 28
impressions, duration of, 31
rate of travel, 31
of visceral perforation, 299
philosophy of, 42
psychic control of, 33
susceptibility to, 28
Panotopon, 186
Paracentesis, 586
Paranephrin, 132
Paraneural anesthesia, 174
Parasacral anesthesia, 462
technic, 465
Paravertebral anesthesia, 454
cervical, 459
Patella, fracture of, 253
Patrick route to third division of fifth nerve,
529
Pelvic neuroses, epidural injections in, 453
Penis, anesthesia of, 368
dorsal nerve of, 364
Oberst method of anesthetizing, 369
Perineorrhaphy, 396
Perineum, anesthetizing, 395
Periosteum, sensibility of, 36
Perirectal abscess, 391
Peritoneum, sensibility of, 297
Peroneal nerve, 246
Peuckart median orbital injection, 506
Physiologic action of local anesthetics, 72
Plantar surface, 256
ë.
Poisoned wounds, 180
Poisoning from local anesthetics, 126
treatment, I 27
Porus trigeminus, 553
Posterior tibial nerve, 245
blocking, 257
Postoperative hernia, 362
Pressure, 58
anesthesia in dentistry, 604
over carotids as means of anesthesia, 18
Prolapse of rectum, 391
Propasin, 96
Prostatectomy, 381
Prostatic abscess, 384
Pterygium, 583
Pterygoid process, 530
Pterygomaxillary fissure, 556, 559
Pterygopalatine fossa, 559
Pudic nerve, 364
blocking, 367
QUINCKE point for spinal puncture, 425
Quinin anesthesia, Ioë
in anorectal operations, Io9, II 2, II4
in circumcision, Io9
in intra-abdominal surgery, II3
in tonsillectomy, II 2
sloughing following, Io8
injections and tetanus, II6
in neuralgia, II 2
RADIAL nerve, 226
paraneural injections of, 226, 232
Radius, nerve-supply of, 214
Reclus solution, 99, IoS
Rectal fissure, 391
fistula, 391
operations, 386
prolapse, 391
ulcer, 391
Rectum, anesthetizing, 386
sensibility of, 331
Recurrent laryngeal nerve, 265
Regional anesthesia, 173
by Schleich infiltration, I75
Resorcin in local anesthetic mixtures, 126
Retromolar fossa, 516
triangle, 516
Ribs, resection of, 285–287
Round ligaments, operations upon, 401, 402
SALPINGo-oophor ECTOMY, 402
Scalp, anesthetizing, 475
624
INDEX
Scalp wounds, 48o
Scarpa's triangle, 248
Schleich’s infiltration, 15o, I52
solutions, 155
theory of pain, 37
Schlösser method of injecting second division
of fifth nerve, 559
third division of fifth nerve, 526
Sciatic nerve, 245
Sciatica, 494
Scopolamin and morphin, 183
Scrotum, nerve-supply of, 366
operations upon, 374
Second division of fifth nerve, injection of,
558
Sensation, distribution of, 36
Sensory nerves, modalities, 26
Sexual neuroses, epidural injections in, 483
Shock, 192
Siegrist method of anesthetizing eye, 584
Skin-grafts, removal of, 249
Skull, operations upon, 481
Sloughing following novocain injections, 578
Small sciatic nerve, 245, 366
Snake-bites, 18o
Sodium bicarbonate after use of cautery, 393
phosphate novocain solutions, 16o
Solutions of anesthetics, 158
Sound vibrations, to produce, 41
Spermatic cord, nerve-supply of, 367
Sphenomaxillary fissure, 497, 556
fossa, 556
Sphygmogenin, I.33
Spinal analgesia, 404
adrenalin in, 432
after-effects, 437
treatment, 45I
anesthetic agents, 408, 413
canula in making puncture, 428
complications and sequelae, 443
course and duration, 435
dangerous effects of, 436
effect upon intestines, 422
upon kidneys, 422, 433
upon nervous system, 444
experimental work in, 441
failures in, 433
history of, 404
indications and contra-indications, 422
in arteriosclerosis, 422
in cardiac disease, 422
in diabetes, 422
in high temperature, 422
Spinal analgesia in hysteria, 422
in locomotor ataxia, 422
in military Surgery, 435
in nervous diseases, 422
in obstetrics and gynecology, 434
in pulmonary disease, 422
in shock, 422
in suppurative processes, 422
in Syphilis, 422
in tuberculosis, 422
Jonnesco method, 450
magnesium salts in, 442
mortality from, 437
movements of solution within canal,
4Io, 426
mucilage of acacia in, 442
needles for, 427
ocular palsies following, 447
oily solutions in, 441
points of puncture, 425
position of patient, 425
preparation of solution, 409
shock in, 423
solution of mucilage of acacia in, 442
strychnin in injection, 424
syringe for, 427
technic of, 423
canal, study of its shape, 414
column, measurements on, 454
cord, anatomy of, 406
Spleen, sensibility of, 317
Sprays, anesthetic, 590
Sterilization of cocain solutions, 164
Sternum, 290
Stomach mucosa, sensibility of, 331
Operations upon, 339
sensibility of, 297, 307, 332
Stone of Memphis, 18
Stovain, 83
hemolytic action of, I61
Strangulated hernia, 357
Strong solutions, action of, I61
Subarachnoid space, 407
Subclavian artery, ligation of, 266
Subconjunctival injections, 581
Subcutin, 95
Subdural space, 407
Subtemporal decompression, 481
Superior dental nerves, 472
laryngeal nerves, 264
blocking, 264
maxillary nerves, 472
Supraclavicular nerves, 283
INDEX
625
Supraclavicular nerves, blocking, 285
Supra-orbital foramen, 484
nerve, 472
Suprapubic cystotomy, 379
in female, 4ol
Suprarenin, I32, 134
Synthetic, I32, I44
Supratrochlear nerve, 472
Swab, use of, 592
Sympathetic nerves, 329, 334
Synovial membranes, sensibility of, 37
Syringes and needles, I65
dental, 599
for deep cranial injections, 529
for spinal analgesia, 427
TABLETS of local anesthetics, I67
Tactile impressions, rate of travel, 31
Teeth, anesthetizing, 6oo
Tendon sheath, sensibility of, 37
Tendons, sensibility of, 37
Tenotomy, 26o
Testicle, nerve-supply of, 367
removal of, 375
Thermo-anesthesia, 28
Thigh, 25o
amputation of, 25o
Thoracic contents, sensibility of, 286
wall, anterior, anesthetizing, 285
Thoracotomy, 286
Thorax and back, 281
nerves of, 281
Throat, 588
Thymol in dental anesthesia, 598
Thyroid gland, changes in, following ligation
of vessels, 279
removal of, 273
vessels, ligation of, 276
Tibia nerve, supply of, 214
Tiefenthal method of anesthetizing tym-
panum, 586
Toe-nail, removal of, 256
Toes, 256
Tongue, anesthesia of, 527
innervation of, 570
removal of, 495, 570
Tonsil, faucial and lingual, 596
Tonsillar tumors, removal of, 496
Toxicology, I.21
Trachea, 268
operations within, 597
sensibility of, 271
40
Tracheotomy, 271
Transthoracic hepatotomy, 287
Trigeminal nerve, 471
Tropacocain, 82
Tubercular laryngitis, alcohol injections in,
271
anesthesin in, 94
Tuffier point of spinal puncture, 425
Turbinate bones, operations upon, 592,
594
Tympanum, anesthetizing, 585
ULNAR nerve, 225
paraneural injections at elbow, 225
in forearm, 225, 233
supply of, 214
Umbilical hernia, 360
Upper and lower extremities, 212
Urethra, female, anesthetizing, 373, 399
male, anesthetizing, 371
Urethral meatus, anesthetizing, 372
strictures, 371
Urethrotomy, external, 373
internal, 371
Urine, incontinence of, epidural injections in,
453
Uterine fibroids, 4or
fixation, anterior, 402
Uterus, sensibility of, 395
Uvula, 596
VAGINAL cystotomy, 399
hysterectomy, 398
outlet, anesthetizing, 397
wall, anesthetizing, 395
Varicocele, 375
Varicose veins of leg, 248, 249
Veins, danger of wounding, I 74, 359
sensibility of, 37, 328
Ventral hernia, 363
Ventrosuspension of uterus, 402
Vesicovaginal fistula, 399
Vessels, sensibility of, 328, 334
Visceral perforation, pain of, 299
sensibility, 328, 334
Volvulus, pain of, 3oo
Von Eiken method of anesthetizing tym-
panum, 586
WARM solutions, use of, 237
Water anesthesia, 63, 392
Wounds, technic of handling, 178
Univ. of w oko an
DEC 28 1914
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Friedenwald and Ruhrah on Diet
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ARA C7/CE OF MEDAC/AVE 9
&= -- Kemp on Stom a ch,
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Diseases of the Stomach, Intestines, and Pancreas. By Robert
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NOTHNAGEL’S PRACTICE
|Diseases of the Stomach -
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Diseases of the Intestines and Peritoneum Second Edition
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Tuberculosis and Acute General Miliary Tuberculosis
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Diseases of the Blood (Anemia, Chlorosis, Zeukemia, and Pseudoleukemia)
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Diseases of the Heart
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Hydrotherapy: A Treatise on Hydrotherapy in General; Its
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Kelly’s Cyclopedia of Ameri-
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Cyclopedia of American Medical Biography. By HowARD A.
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Swan’s Prescription-writing and Formulary
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KEY TO CAPITALIZATION AND PRONUNCIATION.—ALL THE NEW WORDS
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Pusey and Caldwell on X-Rays Second Edition
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Cohen and Eshner's Diagnosis. Second Revised Edition
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– —T-










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