. Local and regional anesthesia; with chapters on spinal, epidural, paravertebral, and parasacral analgesia, and other applications of local and regional anesthesia to the surgery of the eye, ear, nose and throat, and to dental practice. of the ischium(Fig. 107), and if the operative field extends some distance behindand to the side of the rectum, as in fistula, the inferior pudendal willalso have to be blocked on the outer side of the ischium; both proced-ures are discussed under the above heading. When used, this methodshould be combined with a thorough perianal infiltration in thesame way a
. Local and regional anesthesia; with chapters on spinal, epidural, paravertebral, and parasacral analgesia, and other applications of local and regional anesthesia to the surgery of the eye, ear, nose and throat, and to dental practice. of the ischium(Fig. 107), and if the operative field extends some distance behindand to the side of the rectum, as in fistula, the inferior pudendal willalso have to be blocked on the outer side of the ischium; both proced-ures are discussed under the above heading. When used, this methodshould be combined with a thorough perianal infiltration in thesame 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 GENITO-URINARY, ANORECTAL, AND GYNECOLOGIC OPERATIONS 413 the uncertainty of accurately reaching the nerve at the point ofinjection. The following method is much to be preferred, being simpler,quickly executed, and absolutely rehable in producing a perfect sur-gical anesthesia. This technic is so simple and quickly executed that the writeralmost invariably uses it for all operations in this region (hemor-rhoids, fissure, prolapse, etc.) in preference to a general Fig. 108.—Points of injection for surrounding anal canal with zone of anesthesia. (From Braun.) The tissues are first infiltrated subcutaneously around the anusat the mucocutaneous junction, as seen in Fig. io8. It is better tostart the injection an inch or more away in the less sensitive skin,and advance toward this region, when the injection is then carriedout circumferentially, rather than to make the first puncture in thisarea, which is highly sensitive, and will always excite some complaint,and in nervous patients cause them to become uneasy and lose con-fidence in the promise of a painless operation. The author alwaysuses an ethyl chlorid spray on the skin at the point of puncture, first 414 LOCAL ANESTHESIA
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