Regional anesthesia (Victor Pauchet's technique)

Preface

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

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

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

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

(iii)

iv PREFACE.

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

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

B. Sherwood-Dunn.

Chapter I. Page

Advantages of Regional Anesthesia 1

Disadvantages of Regional Anesthesia 5

CHAPTER H.

Syringes 12

Needles 12

Anesthetic 14

General Technique 17

CHAPTER HI.

Cranial Operations Zl

Treatment of Large Wounds in the Soft Tissues, or of Compound Fractures of the Skull 40

Removal of Malignant Tumors of the Cranium, with Bone

Resection 42

Trephining the Temporal Region 43

Exposure of the Cerebellum 46

CHAPTER IV.

Anesthesia of the Gasserian Ganglion 48

Anesthesia of the Trigeminal Nerve Distribution 57

Regional Anesthesia in Rhinology 80

Regional Anesthesia in Otology 85

Regional Anesthesia in Ophthalmology 91

Regional Anesthesia in Dental Surgery 94

Regional Anesthesia of the Face and Jaws 97

Regional Anesthesia of the Tongue, Floor of the Mouth, Tonsils and Palate 105

Regional Anesthesia in Operations of the Neck 109 vi CONTENTS.

CHAPTER V.

PAGE

Anesthesia of the Thorax and Abdomen 128

Intraspinal Anesthesia 128

Nerve-trunk Anesthesia ....... 136

Paravertebral Anesthesia 144

Paracentesis of the Pleural Cavity 153

Thoracotomy for Empyema with Costal Resection 153

Resection of the Second to the Fifth Costal Cartilages for

Rigidity of the Thorax 155

Operations upon the Sternum , 158

Thoracotomy for Abscess of the Lung, etc 158

Operations for Tumor of the Breast 160

Operations in the Axilla 162

Abdomen 162

Operations upon the Stomach 165

Median Hypogastric Incision 167

Operations in the Iliac Fossa 169

Umbilical Hernia 186

Inguinal Hernia 188

Femoral Hernia 195

Operations upon the Kidneys 198

Operations upon the Biliary Passages 199

CHAPTER VI.

Anesthesia of the Genito-urinary Organs and Rectum 200

Anterior Sacral Anesthesia (Pre-sacral) 205

Anesthesia through the Sacral Foramina — Trans-sacral Anesthesia 207

Operations upon the Bladder \ 212

Operations upon the Testicles and Scrotum 214

Operations upon the Penis 217

Operations upon the Posterior Urethra 219

Operations upon the Prostate 220

Operations upon the Vulva and Vagina 220

Operations upon the Anus 224

CHAPTER VII.

page

Upper Extremity 232

Operations upon the Hand 245

Operations upon the Forearm 258

CONTENTS. vii

Anesthesia of the Extremities (continued).

Upper Extremity, Operations at the Elbow 261

Operations upon the Arm 263

Operations upon the Shoulder 264

Lower Extremity 265

Operations upon the Toes 270

Operations upon the Entire Foot 272

Operations upon the Knee 274

Operations upon the Soft Part of the Thigh 277

Conclusions 283

Index 285

CHAPTER I.

GENERAL CONSIDERATIONS.

Advantages of Regional Anesthesia.

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

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

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

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

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

Local or regional anesthesia secures a complete physiological section of the nerves and suppresses completely this influence upon the nerve centers.

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

Absence of Danger from Asphyxia. — Administration of ether or chloroform is generally attended by greater or less respiratory disturbances. Onlookers often have their attention attracted by the patient's difficulty in breathing, due generally to mucus collecting in the mouth and nose, especially in the Trendelenburg position. Not infrequently the operator's attention is arrested by the same difficulty. All of this is absent in injection anesthesia.

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

Special Advantages in Certain Operations. — The fan-like distribution of the nerves after they leave the large nerve trunks permits the performance of extensive operations once the trunk has been anesthetized. Thus a bronchial tumor, or the cervical glands can be removed, or total laryngectomy or external esophagotomy performed after preliminary infiltration of the cervical plexus.

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

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

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

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

(3) It obviates all danger of necrosis of the tissues, such as sometimes occurs in local infiltration where a section of the skin is mobihzed in a plastic operation to cover, a denuded surface and is nourished only by a narrow pedicle.

Disadvantages of Regional Anesthesia.

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

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

When he has become familiar with the depths and directions of the various punctures through exercises upon the skeleton, the student of the method may then repeat the various operations upon the cadaver, using the longer and coarser needles and a fluid containing India ink. Dissection of the more diflicult regions, after such experimentation, will disclose any faults and soon draw the operator's attention to any necessary corrections. Too much time need not be spent in this experimental work, however, before the operator begins upon the living subject, as no harm results from the injection of the fluid. But little actual experience is required for the surgeon to become confident and adept in finding the nerve trunks, this being facilitated by the more or less pronounced sensation referred to the terminal distributions when the point of the needle touches the nerve trunk, or by the insensibility of the surfaces supplied.

It will assist the operator in rapidly gaining confidence and skill if he will use at first a larger amount and a stronger solution and infiltrate a more extensive area.

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

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

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

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

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

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

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

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

Necessarily the operator must have become perfected in the details and technique of the regional form of anesthesia. Any operator who, in the anesthetization of his patients, has had to rely upon the services of different assistants, knows how seldom a good one is found. The number of patients who are insufficiently or imperfectly brought under the anesthetic and bear down or resist during the course of the operation is legion, while not infrequently cases absorb too much of the anesthetic, causing the operator to discontinue his work while the patient is brought back from the danger line. It is not too much to ask, therefore, that the operator intending to make use of regional anesthesia should carefully and completely train himself in the details of the procedure and persevere in his technical practice until he has reached a satisfactory degree of perfection, just as he does in any and every other department of medical practice.

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

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

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

Where the operator is dealing with a private case, it is not often that a few moments more or less will particularly interfere with the type of technique he may select, that which is best in his opinion governing the choice.

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

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

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

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

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

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

GENERAL CONSIDERATIONS. H

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

CHAPTER 11.

ARMAMENTARIUM.

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

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

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

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

ARMAMENTARIUM.

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

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

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

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

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

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

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

Anesthetic. — As anesthetic we have been using neocdine-siirrenine (Corbiere), a French preparation which replaces with perfect satisfaction the German product novocaine-adrenalin. In preparing a considerable amount of the solution, to be kept for some hours, it is best to use the pure procaine,^ to which can be added immediately before use the required quantity of adrenin.

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

The formulas of the mixtures used are as follows: (i) 25 drops of I to 1000 adrenin solution to 200 mils of >4 per cent, procaine solution;

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

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

REGIONAL ANESTHESIA.

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

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

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

the Yi per cent, solutions are those most commonly employed, the latter for all infiltrations.

It is far cheaper to prepare the solution as required than to buy it ready made.

The adrenin and procaine come in glass ampoules. On the evening of the day preceding the operation these are dissolved in boiled salt solution. Even more convenient are the procaine tablets which can be dissolved in boiled salt solution

ARMAMENTARIUM. X7

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

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

The high percentage solutions should be injected very slowly, and in amounts never exceeding 20 to 40 mils of the J^ per cent, solution. Wt have employed, however, as much as 300 mils without any harmful effect.

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

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

General Technique.

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

1 The product termed by Corbiere urocaine.

they supplement each other and are often employed in combination.

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

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

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

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

Operation, which is performed as though the patient were under general anesthesia; the anesthesia should be complete when the patient is brought to the surgeon, and there should be no more question of it during the operation.

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

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

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

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

The Injections. — The syringe (Fig. 4) is held with the thumb and the second and third fingers of the right hand (Fig. 5). By virtue of the flexibihty of the operator's wrist, all pressure other than that in the direct line of the needle is obviated, to avoid breaking of the needle. The latter should never be inserted down to its flange.

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

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

The slight edema resuhing from the subcutaneous injection raises the overlying skin, and the region injected, rendered ischemic by the adrenin, becomes definitely pale.

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

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

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

with needles chosen progressively longer. Again it is indispensable to mark beforehand the sites for these injections by the formation of "intradermal wheals'' which will render the skin insensitive to the introduction of the needle. The wheal consists essentially of an intradermal infiltration of small diameter (Fig. 6).

A fine, short needle mounted on a syringe filled with J^ per cent, solution is introduced almost parallel with the skin surface, with the bevelled edge upward, directly into the thickness of the skin. As soon as the opening of the needle has disappeared, the plunger is pushed down to drive in a little of the solution. A white swelling instantly forms in the tissues, which take on the aspect of ''orange skin.'' One or more wheals, according to requirements, are thus marked out, and through them the needles are subsequently introduced for all the necessary injections.

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

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

ARMAMENTARIUM.

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

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

After a few minutes the skin covering the injected tissue will have become insensible, the solution having anesthetized not only the subcutaneous

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