Practical local anesthesia and its surgical technic

Front matter

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Preface

This book is an expression of the author’s views on the subject of local anesthesia as developed by his observation and by his own experience. Its aim is to present to the medical profession the advantages of local anesthesia to patient and to surgeon, and to describe the practical details of methods of administration and of operative technic employed in its use. As far as possible, stress has been laid upon the particular methods which have proven best in the author’s experience. Spinal anesthesia has been omitted as his experience with it has been limited. Every effort has been made to portray, in as vivid a manner as the ability of the author permits, the simplest and most efficient means of using local anesthesia. At the risk of being tedious, by introducing what might be considered an unnecessarv amount of detail, the author has endeavored to present the methods which have carried him through the critical stages of the various operations.

Illustrations in the form of drawings and photographic reproduc¬ tions have been freely used wherever they were considered of advan¬ tage in helping to clarify the text. To illustrate the feasibility of performing the various types of operation under local anesthesia, case reports have been inserted.

For the sake of convenience the book is divided into three parts:

In Part I, consisting of Chapters I to VI, inclusive, certain problems are considered in connection with anesthesia, including equipment, technic and a description of the sensory nervous system.

In Part II, which comprises Chapters VII to XII, inclusive, the subject has been considered regionally, all portions of the body, aside from the abdomen, being treated.

In Part III, which includes the final six chapters, the surgery of the abdomen is considered.

It is the author’s belief that the actual method of operating has a most important bearing upon the success which will attend any surgical procedure under local anesthesia. Hence points in surgical technic have been described with more than ordinary detail. It is hoped that sufficient descriptive material regarding both the technic of administering anesthesia and the technic of operating has been introduced to point the way with clarity and encourage the surgeon to adopt a certain degree of uniformity in his methods.

VI

PREFACE

The necessity for teamwork among assistants in the treatment of patients and the importance of the psychic factor have been espe¬ cially considered.

The author wishes to express his appreciation of the loyal and untiring efforts of his associates, who have so willingly worked with him in an effort to broaden the application of the local anes¬ thesia method. Especial thanks are due to Drs. S. R. Maxeiner, E. W. Gilroy (deceased), M. E. Rose and C. W. Brunkow: Dr. Maxeiner, who, first as assistant and later as associate, aided the author greatly, especially in the study of the nervous system upon the cadaver; Dr. Gilroy for his experimental work on the toxicity of the local anesthetics; and Drs. Rose and Brunkow for their study and observation regarding the alkaline reserve in rela¬ tion to local anesthesia and special aid in preparing Chapters I and II.

The author desires also to acknowledge the many courtesies ex¬ tended by Dr. Charles A. Erdman, of the University of Minnesota, whose kind offices made it possible to carry out studies in the anatomical laboratory. He is also indebted to Dr. Paul W. Wipperman for proofreading the manuscript and offering many valuable suggestions in relation thereto.

His thanks are also due to Miss Ann Nyquist, I\. N., his former and first psycho-anesthetist, whose efficient services and initiative made manifest the great advantages offered by this now indispens¬ able aid.

In the assembling of this volume the tireless and painstaking efforts of Dr. Brunkow, Miss Ella May Thompson, R. N., who is now the author’s psycho-anesthetist, and his faithful secretaries, Miss Blanche W. Scallen and Miss Helen J. Cribb, R. N., have been invaluable. The author’s thanks are due to the artist, Mr. Ralph L. Witherow, by whom most of the drawings were made. He wishes also to express his thanks to Messrs. Lea & Febiger for the care exhibited and the many helpful suggestions in publishing this book.

To the master technician in local anesthesia, this work will, perhaps, make no appeal, but it is the author’s hope and desire that this book may, in some small degree, help the less experienced to avoid the many pitfalls which the writer has encountered in his own experience with local anesthesia. Furthermore, it is his firm conviction that a simple presentation of the subject, such as this aims to be, will enable the earnest and interested student to improve, to some extent, his ability to use this form of anesthesia, thus increasing his efficiency and providing greater safety and com¬ fort for his surgical patients.

R, E. F.

Minneapolis, Minn., 1923 .

Foreword

The writer, having been selected twenty years ago to review the progress and present the status of Local Anesthesia before an International Congress, experiences peculiar pleasure in the oppor¬ tunity, here afforded, to review again in this masterpiece the enor¬ mous progress made in both the art and science of Local Anesthesia.

With the announcement of the discovery of the first drug (cocain) possessing local anesthetic properties, came a wave of enthusiastic adoption by surgeons of a long-sought ideal. In its wake, as promptly, came disasters and disappointments. Seeking still further, innumerable substitutes were found and lauded—still with similar results. Why there have been so many failures dimming the glory of each new remedy, so much misgiving in the surgical and the lay mind, has never been so clearly presented and con¬ cisely explained as in this book, the result of twenty years’ study and work, concentrated on the solution of this problem.

Induction of local anesthesia in any given area involves ana¬ tomical, surgical and psychic factors which in the past were ignored, overlooked or unthought of by the novice, and which account for the frequent early failures!

However, the problem has been studied from every conceivable angle, and every beneficial influence has been utilized by Dr. Farr, so that his success has been phenomenal and most grati¬ fying; and may be duplicated by anyone willing to profit by his experiences.

With every aspect of the specific problem studied and logically weighed, conclusions have been reached that, while convincing, are presented in a refreshingly modest manner.

His many personally devised improvements in instruments, technic and accessory aids have been by him lightly passed over; his wonderfully systematized approach to his final demonstration that Local Anesthesia now rests upon a fixed and solid foundation is confirmed by his presentation of actual clinical case histories, fully illustrated, for every part of the body, even the brain.

Lewis L. McArthur.

Chicago, 1923.

CHAPTER II. The Local Anesthetics

Cold ..33

Pressure.34

Phenol.34

Cocain.35

Beta-eucain.35

Tropacocain.36

Stovain.37

Alypin.38

Apothesin.38

Allocain-S.39

Nirvanin.39

Quinin and Lrea Hydrochloride.40

Benzyl Alcohol.41

Benzylcarbinol.42

Saligenin (Salicain).42

Butyn.43

Epinephnn.44

Novocain (Procain) . 45

Acidosis Research upon Patients after Using Local Anesthesia ... 48

Relative Desirable Properties of Local Anesthetics.52

CHAPTER HI.

The Anesthesia Problem.

The Patient’s Interests.55

The Choice of an Anesthetic.55

Safety.56

Efficiency.56

Comfort.58

X

Some Special Advantages of Local Anesthesia During Operation . . 61

Advantages Before and After Operation.63

The Attitude of the Patient in Relation to Local Anesthesia and Upon

What it Depends.64

General Intelligence of the Patient.66

The Psychic Aspect of a Surgical Case.. 66

The Question of Discussing the Form of Anesthesia with the Patient 68 The Necessity of Attention to Psychic Aspects by Attendants . . 69

“Psychic Shock,”.70

Preliminary Narcotics.72

Narco-local Anesthesia.72

The Hospital in Relation to the Anesthesia Problem.74

Medical Teaching in Relation to Local Anesthesia.74

The General Practitioner in Relation to Local Anesthesia.75

The Nurse versus the Physician Anesthetist.76

The Surgeon His Own Anesthetist.77

The Progress of Local Anesthesia and Upon What It Depends ... 78

Mixed Anesthesia.78

Psycho-local Anesthesia. 79

Operating by Fractional Method.80

CHAPTER IV. Equipment and Armamentarium

Necessity for Special Equipment.82

The Operating Table.83

Tilting.84

Syringes . 85

Needles for Infiltration.86

Detailed Description of the Pneumatic Injector.92

Other Uses for the Pneumatic Injector Pneumoperitoneum ... 95

Operating Room Lighting.95

The Elephant Trunk Lamp.97

The Automatic Wire-spring Retractor.97

The Automatic Lifter.101

Description of the Automatic Lifter.103

The Goiter Clamp.104

The Prostatic Retractor.106

The Viscera Retainer.106

CHAPTER V. General Technic

The Principles of the Application of Local Anesthesia to Surgery . . Ill

A Definition of the Terms Employed.Ill

Infiltration Anesthesia.Ill

Regional or Conduction Anesthesia.Ill

Infiltration Block.112

Venous Anesthesia.112

Arterial Anesthesia. 114

Parasacral Anesthesia. 119

Trans-sacral Anesthesia . 121

Paravertebral Anesthesia.122

Splanchnic Anesthesia.124

Posterior (Kappis). 124

Anterior Splanchnic Anesthesia (Kappis and Author’s) . . . . 125

Handling the Abdominal Viscera.129

Brachial Anesthesia ........ 129

Narco-local Anesthesia.132 xi

Synergistic Anesthesia.133

The Preparation of a Patient for an Operation Under Local Anesthesia . 135

Psychic.135

The Application of Regional Anesthesia.136

Direct Infiltration versus Regional Anesthesia.137

Desirability of Simplifying the Technic of Local Anesthesia and Some

Advantages of Infiltration Anesthesia.139

The Choice of Methods of Administering Local Anesthesia . . . . 143

Infiltration Anesthesia Technic.144

Some of the Causes of Failure of Local Anesthesia in Abdominal Surgery 147 General Considerations Regarding the Induction of Local Anesthesia after the Time has Arrived for the Giving of the Anesthetic . . . 148

Technic.149

The Initial Wheal.149

Anesthetization of the Skin Line.149

Intradermal Method. 149

The Author’s Subdermal Method.150

The Painless Secondary Intradermal Wheal.150

The Technic of Deep Layer Infiltration.151

Safety of Deep Infiltration.152

The Technic of Skin Incision and Opening the Abdominal

Cavity.153

Surgical Technic and Some of the Adjuncts Demanded by Local Anesthesia 154

Sponging.154

Tying of Ligatures.154

Forceps Tie (Grant).156

The Three-forceps Tie (Author’s).156

The Four-forceps Tie (Author’s).156

The Gauze Retractor.156

Operating Room Deportment.159

The Psycho-anesthetist.160

Surgical Strategy. .161

Music.162

Miscellaneous.162

Hypodermoclysis (Bartlett).162

Skin-grafting—Thiersch’s Method.163

Preparation of Field for Application of Graft . . .163

Preparation of Field for Removal of Graft.164

Pedicle Flaps and Wolff Grafts.164

CHAPTER VI. The Anatomy of the Sensory Nervous System

Nerves of the Head and Face.166

The Trigeminal Nerve.166

The Ophthalmic Nerve.166

The Lacrimal Nerve.166

The Frontal Nerve.166

The Nasociliary Nerve.167

The Maxillary Nerve.167

The Zygomatic Nerve.167

The Mandibular Nerve and Branches.168

The Lingual Nerve.169

The Inferior Alveolar Nerve.169

The Facial Nerve.169

The Glossopharyngeal Nerve.169

The Vagus Nerve.169

The Spinal Nerves.170

The Cervical Nerves.170

The Cervical Plexus.170

The Brachial Plexus.172

The Thoracic Nerves.173 xii CONTENTS

The Lumbosacral Plexus. 175

The Lumbar Nerves.175

The Iliohypogastric Nerve.175

The Ilioinguinal Nerve.176

The Genitofemoral Nerve.176

The Lateral Femoral Cutaneous Nerve.176

The Obturator Nerve.177

The Accessory Obturator Nerve.177

The Femoral Nerve.177

The Saphenous Nerve.177

The Sacral and Coccygeal Nerves.178

The Posterior Femoral Cutaneous Nerve.178

The Sciatic Nerve.178

The Tibial Nerve.179

The Common Peroneal Nerve.180

The Pudendal Plexus and Branches.181

The Perforating Cutaneous Nerve.182

The Pudendal Nerve.182

The Inferior Hemorrhoidal Nerve ..182

The Perineal Nerve.182

The Dorsal Nerve of the Penis.182

The Visceral Branches.182

The Muscular Branches.182

Anococcygeal Nerves.182

The Sympathetic Nervous System.182

The Celiac Plexus.183

Part II

LOCAL ANESTHESIA IN SURGERY OF ALL REGIONS OF THE BODY EXCEPT THE ABDOMEN.

Chapter VII

Local Anesthesia in Surgery of the Head and Face.

The Nerve Supply of the Scalp.185

Anesthesia of the Scalp.186

Duration.189

Excision of New Growths.190

Atheromata.190

Surgery of the Skull.190

Fractures of the Vault of the Skull.190

Operations Upon the Brain.191

Subtemporal Decompression.193

The Ear and Mastoid.194

Anesthesia of the Tympanic Cavity.194

The Nerve Supply of the Face.197

Blocking of the Trigeminus Nerve.198

The Ophthalmic Nerve.198

The Maxillary Nerve.200

The Mandibular Nerve.202

Skin Plastics. 220

Hare-lip.220

CONTENTS xiii

Surgery of the Mouth and Throat.222

The Tonsils.222

Tonsillectomy.222

Infiltration.222

Surgery of the Tongue.224

The Palate.226

CHAPTER VIII. Local Anesthesia in Surgery of the Neck

Advantages.229

Cooperation of the Patient.229

Nerve Supply of the Neck.229

Methods of Inducing Anesthesia.230

Deep Cervical Infiltration.230

Tuberculous Glands and Malignant Disease.232

Thyroidectomy in Non-toxic Cases.237

Anesthetic and Surgical Technic.237

Toxic Thyroids.243

Ligation of the Thyroid Arteries.243

Thyroidectomy in Toxic Cases.243

The Larynx.246

Nerve Supply of the Larynx.246

Laryngectomy.246

Chapter IX

Local Anesthesia in Surgery of the Breast, Thorax and Spine.

Benign Tumors—Frozen Sections. 251

Suppurative Mastitis.254

Technic of Anesthesia for Drainage.254

Malignant Tumors.254

Excision of the Breast.254

Radical Excision.256

The Thoracic Nerves.261

Thoracentesis.262

Anesthesia Technic.262

Costectomy.263

Empyema.264

Negative Pressure.264

Massive Rib Resections.264

Surgery of the Spine.267

CHAPTER X. Local Anesthesia in Surgery of the Extremities

Application of Local Anesthesia to Fluoroscopic and Radioscopic

Examination.271

Local Anesthesia of the Hands and Feet.271

Local Anesthesia of the Fingers and Toes.272

Transverse Infiltration Block.275

XIV

The Reduction of Fractures and Dislocations in Children . . . 278

The Reduction of Malunited Fractures in Children.281

Bone Transplants.283

Amputations.286

The Upper Extremities.286

The Lower Extremities.287

Suppurative Arthritis ..289

Technic of Anesthesia for Drainage.289

Osteomyelitis.290

Acute Osteomyelitis.290

Technic of Anesthesia for Drainage.290

Chronic Osteomyelitis.290

Choice of Methods of Producing Local Anesthesia in the Upper Extremities 291

Surgery of the Shoulder and Clavicle.291

Nerve Supply of the Shoulder and Clavicular Region.291

Brachial Anesthesia.292

Surgery of the Elbow-joint.294

Arthroplasty.294

Surgery of the Wrist.297

Nerve Supply of the Wrist.297

Surgery of the Hip.297

Nerve Supply of the Lower Extremity to the Region of the Hip-joint 297

Open Operation.298

Fractures and Dislocations..299

Arthroplasty of the Hip.302

Fracture of the Femur.302

Closed Operation.302

Open Operation.303

The Knee-joint. 305

The Nerve Supply.305

Fracture of the Patella.307

Floating Cartilages.307

The Leg. 308

Fractures, Closed Operations.308

Surgery of the Ankle-joint.310

Special Fractures.310

Pott’s Fracture.310

The Cadivilla Pin.311

Hallux Valgus (Bunions).311

Varicose Veins of the Leg. . 312

CHAPTER XI. Local Anesthesia in Surgery of the Genito-urinary System

Anesthesia and Genito-urinary Surgery.315

Local Anesthesia in Surgery of the Kidneys.316

CONTENTS XV

Local Anesthesia in Surgery of the Kidneys—•

The Kidney. 319

Sensation. 319

Incision. 319

Delivery of the Kidney.321

Calculi ..323

Technic.324

Grave Surgical Problems.325

The Bladder.328

Cystoscopy.328

Suprapubic Cystotomy.329

Method of Opening Bladder.329

Local Anesthesia in Suprapubic Prostatectomy.331

Technic of Infiltration.331

Prostatic Retractor.332

Perineal Prostatectomy. Abscess.338

The Male Urethra.338

Stricture.338

The Penis.340

Circumcision.341

Amputation of the Penis for Malignant Disease.341

Hypospadias.341

Varicocele.341

Skin Sterilization.341

Technic of Infiltration.342

Hydrocele—Orchidectomy—Vasectomy.342

Technic of Infiltration.343

Vasotomy.344

The Female Genitalia (External).344

Methods of Obtaining Anesthesia.345

Psychic Considerations.346

Vaginal Examinations in Virgins.348

Operations upon the Labia—Cysts—Neoplasms—Abscesses . . . 348

The Nerve Supply.348

Operations upon the Clitoris.349

The Nerve Supply.349

Operations upon the Perineum.349

The Nerve Supply of the Perineum.349

Perineorrhaphy.349

Operations upon the Cervix and Uterus—Curettage.352

The Nerve Supply.352

Anterior Colporrhaphy.354

Interposition Operation.354

Infiltration Block.354

Vaginal Hysterectomy.356

Atresia of the Hymen.357

Artificial Vagina.358

Pelvic Abscess in Women ..360

XVI

Chapter XII

Local Anesthesia in Surgery of the Rectum and Anus.

Preparation of the Patient.362

Choice of Local Anesthetic Methods.362

Nerve Supply of this Region.363

Technic of Circumferential Infiltration.363

Sphincter Divulsion.366

Rectal Examination.368

Hemorrhoids, Ulcers, Fissures and Polypi.369

Fistula-in-Ano.369

Infiltration Block.370

Carcinoma of the Rectum.373

Prolapse of the Rectum.373

Postoperative Comfort.377

Quinin and Urea Hydrochloride ..377

Part III. Local Anesthesia In Surgery Of The Abdominal

WALL AND CAVITY.

CHAPTER XIII. Local Anesthesia in Surgery of the Abdomen

Intraperitoneal Pain Sense.379

Position of the Patient.384

Retraction.385

Direction, Site and Choice of Incisions. 385

The Resultant Scar.387

Relative Importance of the Division of the Muscular as Com¬ pared with Aponeurotic Tissue.388

Conservation of the Blood Supply.389

Conservation of the Nerve Supply.389

Anticipated Pathology.390

Facility with Which Incisions May be Made and Closed . . 390

The Relaxation Afforded During and After Operation . . . 391

Technic.391

Closure. 394

The Making of the Incision. 397

Technic. 397

Muscular Relaxation.398

Duties of the Psycho-anesthetist.398

Abdominal Exploration. 399

The Examination of the Abdominal Organs.400

Viscero-parietal Adhesions ..401

CONTENTS xvii

Chapter XIV

Local Anesthesia in Surgery of the Abdominal Wall (Hernia).

Inguinal Hernia.402

Skin Sterilization.403

The Induction of Local Anesthesia.403

Femoral Hernia.406

Incisional Hernia.406

Transplantation of Fascia.407

Epigastric Hernia.411

Umbilical Hernia and Lipectomy.411

Strangulated Hernia.415

CHAPTER XV. Local Anesthesia in Surgery of the Upper Abdomen

Position of the Patient upon the Operating Table.419

Avoidance of Clamps.420

Gastroenterostomy (Anterior).420

Gastroenterostomy (Posterior).421

Ulcers.423

Perforated Gastric and Duodenal Ulcers—Acute and Chronic 423

Sleeve Resection.427

Neoplasms (Malignant).428

Resection for Carcinoma.428

Hypertrophic Pyloric Stenosis.430

The Liver.438

Cysts, Abscess and Rupture.438

Opening of Abdominal Cavity.441

Cholecystostomy.441

Sensation of the Gall-bladder.441

Exposure.441

Anterior Splanchnic Anesthesia.443

Technic of Exposing the Gall-bladder.446

The Method of Removing the Gall-bladder.446

Bile Ducts.453

Choledochotomy.453

The Pancreas.457

The Spleen.458

CHAPTER XVI. Local Anesthesia in Surgery of the Intestines

Special Considerations.459

Diagnosis.459

Treatment of Simple Conditions.459

Treatment of Complicated Conditions.460

Resection for Cancer.460

Colostomy.463

Technic of Operation.463

Intussusception.463

Intussusception in Children.465

Tuberculous Peritonitis.466

Intestinal Obstruction from Other Causes.468

Technic of Temporary Drainage of Distended Bowel.469

The Rubber Towel Method (Author’s).469

Enterostomy.470

Peritonitis Ileus.470

CHAPTER XVII. Local Anesthesia in Surgery of the Appendix

Appendicitis.471

Special Considerations.471

Acute or Subacute.471

Medical Management.471

Surgical Management.471

Preoperative Management.471

Operative Management. 471

Effect of Anesthesia upon Postoperative Course . . . . 472

Position upon the Operating Table.472

Incisions.472

Chronic Appendicitis.472

The Transverse Abdominal Incision.473

Technic of Subdermal Infiltration.476

Technic of Deep Infiltration.476

Technic of Opening the Abdomen.478

Technic of Meso-appendix Infiltration.478

Technic of Delivering Appendix.479

Appendicectomy under Varying Conditions.480

Acute Appendicitis.480

Abdominal Infiltration and Muscular Relaxation.481

Technic of Delivering Acute Appendix.482

Intra-abdominal Abscess.. . 484

Technic for Drainage.484

Superficial Abscess.486

Technic for Drainage.486

The Appendix and Pelvis.487

Special Considerations.487

Position upon Operating Table.488