Brit. J. Anaesth.
(1966), 38, 753
PHYSICS APPLIED TO ANAESTHESIA
VI: GASES AND VAPOURS (2)
BY
D. W. HILL
Research Department of Anaesthetics, Royal College of Surgeons of England, London
Isotherms.
Boyle's law says that for a given mass of gas at
a constant temperature, the product of pressure
and volume is constant. In mathematical terms,
the equation PxV=constant is a rectangular
hyperbola. The value of the constant depends on
the temperature. A series of smooth curves (iso-
thermals) is obtained for different temperatures
as shown in the upper part of figure 1 for nitrous
oxide (Couch and Kobe, 1961). Above a certain
temperature, known as the critical temperature,
the volume diminishes smoothly as the pressure is
increased. Below this temperature, however, the
curves start to exhibit a plateau. Over this portion
liquefaction of the gas occurs and the pressure
remains constant during this change of state.
When all the nitrous oxide has been liquefied, a
small decrease in volume is acompanied by a
large increase in pressure because the liquid is
much less compressible than the gas. Above its
critical temperature, a substance cannot exist as
a liquid, however much pressure is applied. Dur-
ing condensation, nitrous oxide behaves like a
vapour. There is no sharp difference between the
terms gas and vapour; the term vapour is usually
taken to refer to the gaseous state of a substance
which at both room temperature and pressure is
a liquid. Thus nitrous oxide can be liquid in a
cylinder at room temperature but only under in-
creased pressure, whereas ether can be a liquid
at room temperature and pressure.
The critical temperature of nitrous oxide is
36.5 °C, and just below this temperature it has a
pressure of 74 atmospheres. At 20° C, a pressure
of 51 atmospheres (750 p.s.i.g.) is required to
liquefy nitrous oxide. The curves in figure 1 are
known as isothermals. A similar set can be drawn
for carbon dioxide. The critical temperature for
carbon dioxide is 31.1°C. At 20°C, the pressure
in a cylinder containing some liquid carbon di-
oxide is 56 atmospheres (825 p.s.Lg.). Cyclopro-
pane has a critical temperature of 125 °Q and a
"full" cylinder of cyclopropane also contains both
liquid and gas. At 20°C, the pressure in a cylin-
der containing both liquid and gaseous cyclopro-
pane is 6.3 atmospheres (78 p.s.i.g.).
The withdrawal of gas from a nitrous oxide
cylinder.
A "full" nitrous oxide cylinder contains both
liquid and gaseous nitrous oxide if the ambient
temperature is below the critical temperature of
nitrous oxide, 36.5°C and 97.7°F. At 20°C, the
saturated vapour pressure of nitrous oxide is 51
atmospheres (750 p.si.g.) so that this is the pres-
sure read on the cylinder contents gauge if one is
fitted. When gas is withdrawn, at temperatures
below 36.5 °C, liquid nitrous oxide boils, replen-
ishing the gas which is drawn off. The heat neces-
sary to produce this evaporation comes from the
atmosphere of the room and has to be transferred
through the cylinder wall. If the rate of with-
drawal is sufficiently high, a frost may form on
the bottom of the cylinder. Expansion of the issu-
ing gas at the cylinder valve may cause a marked
cooling and precautions are taken during manu-
facture to ensure that the gas is dry in order to
prevent blocking of the valve by ice formation.
The contents gauge indicates a steady pressure
of 750 p.s.i.g. as long as any liquid nitrous oxide
remains. When this has all evaporated, only p s e -
ous nitrous oxide is left, and the pressure then
falls steadily until the cylinder is empty. This
sequence is in contrast to that in an oxygen cylin-
der; in this instance the pressure falls steadily as
gas is withdrawn.
In hot climates where the ambient temperature
is above 36.5"C (97.7°F), the cylinder will always
contain only gaseous nitrous oxide. At 37°C, the
pressure in the cylinder is 1,125 p.s.i.g., and this
falls steadily as gas is withdrawn. Oxygen, nitrous
oxide and carbon dioxide cylinders are tested to a
pressure of 3,000 p.sj.g. in the United Kingdom.
754 BRITISH JOURNAL OF ANAESTHESIA

300
o - SAMPLE TWO
• - SAMPU TM«EE
280

01 10 12 14 l( IB 10 22 24 24

FIG. 1
A series of isothermals for nitrous oxide.
PHYSICS APPLIED TO ANAESTHESIA—VI
A full oxygen cylinder has a pressure of 132
atmospheres (1965 p.si.g.)
Cylinders containing carbon dioxide, cyclopro-
pane and nitrous oxide are never rilled to the
point at which they contain only liquid Under
these circumstances, any slight increase in the
ambient temperature would raise the pressure in
the cylinder to dangerously high values, since
the liquid is almost incompressible. The degree
of filling of a cylinder with liquid plus gas is
expressed in terms of the filling ratio. This is
given by the fraction
Weight of substance (liquid + gas) in cylinder.
Weight of water required to fill cylinder completely.
Cylinders of nitrous oxide are normally filled to a
ratio of 0.75, a "full" cylinder then containing
some nine-tenths of liquid, the rest being gas.
Weighing is the only satisfactory way of keeping a
check on the contents of cylinders containing
carbon dioxide, cyclopropane or nitrous oxide.
Suppose that a gram-molecular weight of nitrous
oxide (44 g) occupies a volume of 22.4 1. at NTP,
then the density of gaseous nitrous oxide is
(22.4/44)=0.509 l./g. Considering a mass of 1 g
of nitrous oxide, Charles's Law states that the
volume it occupies is directly proportional to the
Absolute temperature, so that the density at 15 °C
is 0.509 x (288/273)=0.537 l./g. A 100-gaUon
cylinder contains 455 litres of nitrous oxide (when
allowed to expand to the conditions of 760 mm
Hg), which thus has a mass of 455-=-0.537 at
15 °C, i.e. 847 g (29.9 oz.). Thus each ounce of
nitrous oxide is equivalent to 15.2 litres of gas.
The average weight of an empty 100-gallon
cylinder is 9^ lb.
This is also the weight empty of a "2 lb."
carbon dioxide cylinder. This holds 106.6 gallons
of carbon dioxide when allowed to expand to
the conditions of 15 °C, 760 mm Hg, which is
equivalent to 485 1., and has a mass of 33 oz.
Each ounce is equivalent to 14.7 litres. The
weight of an empty 80-gallon cyclopropane cylin-
der is similarly 9.5 lb., and this contains 364
litres when allowed to expand to the conditions
of 15°C and 760 mm Hg.
The mass of the cyclopropane is 22.85 oz., each
ounce being equivalent to 16 litres.
755
The production of pre-mixed cylinders of nitrous
oxide and oxygen.
If the pressure inside a nitrous oxide cylinder
is raised above 51 atmospheres (750 p.s.i.g.),
liquid nitrous oxide condenses. If the cylinder is
first filled with gaseous nitrous oxide to a pressure
of 750 p.s.i.g., and filled up with oxygen to a
total pressure of 2,000 p.s.i.g.,then the percentage
nitrous oxide by volume in the mixture is 38 per
cent (assuming Dalton's law of partial pressures
is obeyed). On this basis it would appear that 38
per cent is the strongest mixture of nitrous oxide
that could be prepared in a cylinder filled to
2,000 p.s.i.g. at 20°C. It is found experimentally,
however, that if the proper technique is used it is
possible to prepare mixtures containing up to 70
per cent nitrous oxide in cylinders at 2,000 p.s.i.g.
Attention has been concentrated on the produc-
tion of analgesic mixtures of 50 per cent nitrous
oxide and 50 per cent oxygen prepared in light-
weight alloy cylinders for uss in domicilliary mid-
wifery practice, and for postoperative analgesia.
A good account of the method for producing such
mixtures has been given by Gale, Tunstall and
Wilton-Davies (1964). If maintained at room tem-
perature a cylinder containing a mixture of 75
per cent nitrous oxide and 25 per cent oxygen
may be used without any change occurring in
the composition of the issuing gas, and will not
contain any liquid phase at any stage of compres-
sion or decompression. Because of the need to
keep pre-mixed cylinders containing anaesthetic
concentrations of nitrous oxide at room tempera-
ture, these have not come into widespread use on
anaesthetic machines. With a 50 per cent nitrous
oxide analgesic mixture, the composition of the
mixture will remain constant unless the tempera-
ture of the cylinder is lowered to — 8°C and the
pressure of the contents reduced to some 705
p.s.i.g. The separation of the mixture into its two
components could be dangerous because if the
nitrous oxide liquefied, gaseous oxygen would
be drawn off first, the last part of the cylinder
contents becoming progressively more hypoxic
until finally pure nitrous oxide emerged. Gale,
Tunstall and Wilton-Davies (1964) discuss in
detail the probability of this occurring in the
United Kingdom. They conclude that, in prac-
tice, conditions are unlikely to be encountered in
which the percentage of oxygen in the mixture
756
will fall below 21 per cent (P=0.0001). The cylin-
der has to be brought in from the cold into a
room, and the heat input from the room air is
sufficient to compensate for any cooling occurring
due to withdrawal of the mixture at flow rates
of less than 10 l./min. If any doubt should exist
concerning the state of a cylinder containing a
50 per cent mixture, Gale, Tunstall and Wilton-
Davies suggest two simple precautions. The
cylinder should be warmed until any frost or ice
disappears, and should then be inverted three
times after warming. The effect of adding oxygen
under pressure to nitrous oxide is to lower the
critical temperature of the mixture so that a
liquid phase cannot exist. Thus the critical tem-
perature of the mixture of 50 per cent nitrous
oxide and 50 per cent oxygen is - 7 ° C, and the
critical pressure 705 p.s.i.g. Phase changes at the
critical point are minimal, so any change in com-
position of the gas mixture is difficult to detect.
The temperature of - 8°C appears in the discus-
sion on mixture stability because this is the
highest temperature at which changes in the
composition of the mixture are readily apparent.
The variation of atmospheric pressure with
height.
It is well known that the atmospheric pressure
decreases with increasing height above the earth's
surface, and it is interesting to determine the law
governing the process. Let P be the atmospheric
pressure in dyne/sq.cm at a height of H cm in
an atmosphere at a constant temperature of 7*°K.
At a slightly greater height of (H+h) cm, the
pressure will be less than P by an amount equal
to the weight of a layer of air h cm thick and
1 sq.cm in cross-section. If d is the density of air
in g/ml at a height of H cm, then p= -dx gxh
dyne/sq.cm. If it is assumed that the air obeys
the ideal gas law then
(PV/T) = constant = R
(R is the gas constant for a gram-molecule of gas
and has a value of 8.313 x 10' erg per gram-
molecule per °C). Dividing both sides of the
equation by M, the effective molecular weight of
air,
(PV/M) = (RT/M)
which becomes (P/d) = (RT/M), so
d=(PM/RT), giving p= - (PM/RT)xgxh.
BRITISH JOURNAL OF ANAESTHESIA
Rearranging, p/P= - (Mg/RT) x h.
Integrating both sides of this equation we arrive
at the simple exponential equation
log,(P)= -(Mg/RT)H + a. constant.
At H=O, let P = t h e barometric pressure B,
then log, (P/B)=-(Mg/RT)H.
That is P^B.e-w*/*""-
Thus the pressure should fall off exponentially
with height. When a height equal to (Mg/RT)
cm is reached the pressure should be l/e of
atmospheric. If the simple theory held, this would
occur at a height of 23,400 feet but in practice the
pressure is found to be 280 mm Hg at 25,000 feet.
The solubility of gases.
In general, gases are soluble in liquids. Experi-
mentally, it is found that the amount of a given
gas which dissolves in a given liquid is directly
proportional to the pressure of the gas. This is
Henry's Law. The amount of gas which goes into
solution depends on the temperature of the
liquid. The higher the temperature, the less the
amount which goes into solution. At a given tem-
perature, when no more gas will dissolve in the
liquid, the liquid is said to be fully saturated with
the particular gas at that temperature and pres-
sure. When a state of equilibrium has been
attained, it is said that the gas in solution exerts
the same tension as the partial pressure of the gas
concerned present above the liquid. Thus we
speak of the "tension" of carbon dioxide or oxy-
gen in blood.
Current practice is to use a polarographic
electrode to measure oxygen tension in blood, and
a carbon dioxide electrode to measure the carbon
dioxide tension of blood (Severinghaus and
Bradley, 1958; Severinghaus, 1962; Fatt, 1964).
Before suitable electrodes were developed, the
Riley bubble method (Riley, Campbell and Shep-
ard, 1957) was used for the determination of
oxygen and carbon dioxide tensions in blood. A
small bubble is introduced into the blood sample
contained in a syringe, the volume of the bubble
being of the order of 1/100 that of the blood.
The gases in the blood and bubble come into
equilibrium and the composition of the bubble
can then be determined as a volume percentage
(fractional concentration Fco.) by means of a
Scholander microgas analyzer (Scholander, 1947).
PHYSICS APPLIED TO ANAESTHESIA—VI
From a knowledge of the dry barometric pressure,
the percentage concentrations by volume of the
gases can be converted into tensions. Strang
(1961) has applied a mass spectrometer to the
analysis of the bubble. The Po2 of a liquid in
equilibrium with air (20.95 per cent v/v oxygen)
at a barometric pressure of 769 mm Hg and at
37°C is
(760 - 47) x (20.95/100) = 149 mm Hg
(the saturated vapour pressure of water at 37°C
is 47 mm Hg).
Solubility coefficients.
The Bunsen solubility coefficient (a) is defined
as the volume of gas reduced to 0°C and 1 atmos-
phere pressure dissolved by unit volume of sol-
vent at the temperature of the experiment under
a partial pressure of the gas of 1 atmosphere. If
we are considering one gas dissolving in water,
then the pressure of the gas minus the saturated
vapour pressure for water at the temperature con-
cerned equals 1 atmosphere. If v0 is the volume of
gas dissolved by unit volume of solvent reduced
to STP conditions, V is the volume of solvent,
and p is the partial pressure of the gas in atmos-
pheres, then
a = (v0/Vp).
The Ostwald solubility coefficient (X) is defined
as the volume of gas, measured under the tem-
perature and pressure at which the gas dissolves,
taken up by unit volume of the liquid. If v is the
actual volume of dissolved gas, measured at the
experimental temperature T° Absolute, and at
the partial pressure of the gas p atmospheres,
then assuming the gas laws to be obeyed,
v=Tvo/ToP where To is 0°C (273 K)
i.e. 273° Absolute. By definition the Ostwald
solubility coefficient is l = v/V, thus A = a T/273
or ). = a ( l +0.003670 where t is in °C. The
Bunsen absorption coefficient is the customary
manner in which solubilities are expressed in the
International Critical Tables. Thus Orcutt and
Seevers (1937) and Larson, Eger and Severing-
haus (1962) measure Ostwald coefficients and
convert to Bunsen coefficients.
In tables of the solubilities of gases in water,
the solubility coefficient is listed in terms of the
number of ml of the gas, measured at 0°C and
760 mm Hg, which dissolve in 1 ml of water at
757
the temperature stated, and when the pressure of
the gas minus that of the water vapour is 760
mm Hg. Thus 0.88 ml of carbon dioxide will dis-
solve in 1 ml of water at 20 °C and 760 mm Hg.
Whole numbers are obtained by considering the
volume of gas which will dissolve in 100 ml of
water. This gives the following solubility co-
efficients at 20° C: carbon dioxide 88, nitrogen
1.6, nitrous oxide 63, and oxygen 3. The high
solubility of nitrous oxide makes it necessary to
use saturated caustic in a Haldane apparatus
when oxygen and carbon dioxide measurements
have to be made in the presence of nitrous oxide
(Nunn, 1958). The solubility of oxygen in blood
is discussed by Hedley-White and Laver (1964).
The solubility of nitrous oxide in water and in
canine blood has been measured by Sy and Has-
brouck (1964), and the use of a gas chromato-
graph to measure the solubility of nitrous oxide
is described by Borgstedt and Gillies (1965).
Applications to hyperbaric oxygen therapy.
The composition of alveolar air when breathing
air or oxygen at a pressure of 1 atmosphere abso-
lute, or oxygen at a pressure of 2 atmospheres
absolute is given below.
14) Total
Inspired Alveolar Alveolar Alveolar Alveolar pressure
gas PO, Pco, PN, PH,O (mm Hg)
1ATA
air 105 40 568 47 760
1 ATA
oxygen 673 40 0 47 760
2 ATA
oxygen 1433 40 0 47 1520
At 1 atmosphere, breathing air, haemoglobin is
97 per cent saturated, the amount of oxygen dis-
solved in the plasma is 0.3 ml/100 ml, and the
total oxygen content (dissolved plus combined) is
20 ml/100 ml. When pure oxygen at 1 atmos-
phere is breathed the partial pressure of oxygen
in the alveoli rises from 105 to 673 mm Hg, an
increase of 6.7 times. As a result, the dissolved
oxygen rises to 2 ml/100 ml. The haemoglobin
becomes fully saturated, and the additional
amount of oxygen now carried in the blood as a
result of breathing pure oxygen is 2.5 ml/100 ml
of blood. The total percentage increase of oxygen
carried in the blood is only some 10 per cent of
758
the original 20 volumes per cent. However, the
increase of Po2 from 105 to 673 mm will greatly
assist oxygenation of the tissues, since this is a
diffusion process and depends on the tension
gradient between the blood supply and the tissue
concerned. When oxygen at 2 atmospheres abso-
lute pressure is inspired, the dissolved oxygen
increases in proportion to the partial pressure to
4 3 ml/100 ml. The pressure increase from 1 to 2
atmospheres causes an extra 2.3 ml/100 ml in
the amount of oxygen carried by the blood, Le.
a total of 4.8 ml/100 ml above that carried when
air is breathed at normal atmospheric pressure.
Smith and associates (1963) found, in dogs, that
the use of oxygen at 2 atmospheres absolute in-
creased the duration of "safe" circulatory arrest
from 5 to 8 minutes at normal temperature, and
from 20 to 30 minutes at 28 °C.
The solubility of volatile anaesthetics in oil.
Nunn (1960) discussed the solubility of chloro-
form vapour in oleyl alcohol, and showed that
the uptake of chloroform vapour by oil is not
comparable with its uptake by water. At tensions
corresponding to the saturated vapour pressure,
there is a marked deviation from Henry's Law,
the solubility coefficient rising towards infinity.
At the lower values of tension, chloroform appears
to have a finite solubility coefficient. Nunn showed
that the solubility of volatile anaesthetics in oil can
be evaluated by the use of Raoult's Law. This
states that in a solution of two liquids, the vapour
pressure of each constituent is proportional to the
number of mols of that substance present in unit
volume of solution. For a pure liquid, the vapour
pressure will be the saturated vapour pressure.
Thus it follows that for a mixture p = p0J(. where
p is the vapour pressure exerted by one compo-
nent of the mixture, p0 is the saturated vapour
pressure of the pure component concerned at the
temperature of the mixture, and X is the mol
fraction of the component concerned in the mix-
ture. The mol fraction of any constituent in a
mixture is defined as the number of mols (gram
molecules) of the constituent divided by the total
number of all mols in the mixture. It is easier to
use volume fractions provided that allowance is
made where necessary for the fact that equal
numbers of molecules of different liquids occupy
different volumes even under identical conditions
BRITISH JOURNAL OF ANAESTHESIA
of temperature and pressure. This is in contrast
to gases which obey Avogadro's hypothesis that
equal volumes of gases at the same temperature
and pressure contain equal numbers of molecules.
The number of molecules contained in 1 cc of
an ideal gas is known as Loschmidt's Number
(2.687 x 1019). When the anaesthetic vapour is
in equilibrium with an anaesthetic oil mixture,
the partial pressure in the vapour phase will
equal the pressure of the anaesthetic in the mix-
ture. Thus
F.V>
P» = PO p y y Tp
where p a is the partial pressure of the anaesthetic
vapour, V* is the volume of liquid anaesthetic
in the mixture, V oil is the volume of oil in the
mixture, F is the mol volume of oil divided by
the mol volume of anaesthetic and P o is the
saturated vapour pressure of the pure anaesthetic
at the temperature concerned. T h e mol volumes
are obtained by multiplying the relevant mol
fractions and densities. If the ratio VJVoQ. is
known, then the volume of anaesthetic taken up
by unit volume of oil can be calculated. Thus
•vjvoa= *'
There is considerable experimental evidence to
show that the solubility of volatile anaesthetics
does obey Raoult's Law over the clinical range
of concentrations.
REFERENCES
Borgstedt, H. H., and Gillies, A. J. (1965). Deter-
mination of the solubility of nitrous oxide by gas
chromatography. Anesthesiology, IS, 675.
Couch, E. J., and Kobe, K. A. (1961). Volumetric be-
haviour of nitrous oxide. J. Chem. and Engng.
Data, 6, 229.
Fatt, I. (1964). Rapid responding carbon dioxide and
oxygen electrodes. J. appl. Physiol., 19, 550.
Gale, C. W., Tunstall, M. E., and Wilton-Davies,
C C. (1964). Pre-mixed gas and oxygen for mid-
wives. Brit. med. J., 1, 732.
Hedley-White, J., and Laver, M. B. (1964). O, solu-
bility in blood and temperature calibration factors
for Po,. J. appl. Physiol., 19, 901.
Larson, C P., Eger, E. I., and Severinghaus, J. W.
(1962). Ostwald solubility coefficients for anaes-
thetic gases in various fluids and tissues. Anes-
thesiology, 23, 686.
Nunn, J. F. (1958). Respiratory measurements in the
presence of nitrous oxide. Brit. J. Anaesth., 30,
254.
(I960). The solubility of volatile anaesthetics in
oil. Brit. J. Anaesth., 32, 346.
 PHYSICS APPLIED TO ANAESTHESIA—VI 759
Orcutt, F. F., and Seevers, M. H. (1937). A method Severinghaus, J. W., and Bradley, A. F. (1958).
for determinimj the solubility of gases in pure Electrodes for blood and gas Pco,, Po, and blood
liquids or solutions by the Van Slyke-Neill mano- pH. J. appl. Physiol, 13, 515.
metric apparatus. J. biol. Chem., 117, 501. Smith, C, Ledingham, J. McA., Norman, J. N.,
Riley, R. L., Campbell, E. J. M., and Shepard, R. H. Douglas, T. A., Bates, E. M., and Lee, F. D.
(1957). A bubble method for estimation of Pco, (1963). Prolongation of the time of "safe" circu-
and Po, in whole blood. J. appl. Physiol., 11, 245. latory arrest by preliminary hyperbaric oxygena-
rion and body cooling. Surg. Gynec. Obstet., 117,
Scholander, P. F. (1947). Analyser for accurate estim- 411.
ation of respiratory gases in one-half cubic centi- Strang, L. B. (1961). Blood gas tension measurement
metre samples. J. biol. Chem., 167, 235. using a mass spectrometer. 7. appl. Physiol., 16,
562.
Severinghaus, J. W. (1962). Electrodes for blood and Sy, W. P., and Hasbrouck, J. D. (1964). Solubility of
gas Po u Pco, and blood pH. Ada anaesih. scand., nitrous oxide in water and in canine blood. Anes-
Suppl. 11, 207. thesiology, 25, 59.

CORRESPONDENCE
VENOUS COMPLICATIONS FOLLOWING THIOPENTONE Table showing the incidence of bruising, and the
Sir,—I was very interested to read the article in the severity of bruising with the various injection sites,
February issue by Hewitt and his colleagues entitled methods of haemostasis and needle sizes.
"Clinical studies of induction agents. XTV: A com-
parative study of venous complications following thio- 1
pentone, methohexitone and propanidid" {Brit. J. (minimal 2 3
Anaesth., 38, 115). Their findings concerning bruising bruise (a bruise (a bruise
after intravenous injections parallel those of an investi- 0 less than 1 to 2 cm larger
gation which I carried out recently. In this the inci- (no 1 cm maximum than
dence and size of haematoma following intravenous bruise) diameter) diameter) 2 cm)
injections into veins in the antecubital fossa and
dorsum of the hand were studied, using different Method A 42 6 1 1
methods of haemostasis and needle size. The patients 84% 12% 2% 2%
involved in this study were undergoing routine general, Method B 25 10 13 2.
orthopaedic or gynaecological surgery. The solution 50% 20% 26% 4%
injected was 2.5 per cent thiopentone which was Method C 39 7 3 1
used for induction of anaesthesia. The site of injection, 78% 14% 6% 2%
method of haemostasis and size of needle were varied Method D 41 6 3 0
in five ways. Gillette disposable needles were used. 82% 12% 6%
Method A. A number 12 needle (23 s.w.g.) was Method E 44 5 1 0
used and the injection made into a vein in the ante- 88% 10% 2%
cubital fossa. Following injection a pad was pressed
over the injection site and the needle withdrawn. The
arm then bent at the elbow. This method is open to fossa vein produced less chance of a bruise, and
criticism but is very commonly used and served as a smaller bruises, than on the dorsum of the hand. The
baseline. incidence of bruising at that site could be reduced by
Method B. Using a number 12 needle, the injection a careful and planned method of haemostasis or use
was made into a vein on the dorsum of the hand and of a smaller needle. Obviously the frequency of bruis-
an assistant was requested to press on a gauze pad ing with method B is to some extent dependent on
until he thought the tendency to bleed was past. the experience of the assistant With the larger needles
Method C. Using a vein on the dorsum of the hand, method D gave the best results but occupied an
with a number 12 needle, then strapping a gauze pad assistant at a busy period during induction of the
in place before removing the needle. anaesthetic, method C probably being the most useful
Method D. Using a number 12 needle, and a vein in practice.
on the dorsum of the hand, haemostasis was obtained It is thought that these findings are of interest, as
by pressure on a gauze pad for a measured 4 minutes. after a major operation a bruised hand may not cause
Method E. As for method C but using a size 17 comment but many operations are comparatively minor
needle (25 s.w.g.). and a bruise can cause pain for a number of days,
In methods B to E the hand was placed or held whilst the patient displays the marks of anaesthesia
above heart level after the injection. The methods A for 10 to 14 days or more. However, it should be
to E were used in stria rotation, so that a random emphasized that the dorsum of the hand is a safer
selection of patients and methods was obtained. injection site than the antecubital fossa, and any
The injection site was inspected immediately after number of bruises are preferable to an injection into
the operation and again after 24 to 48 hours. The the brachial artery.
results obtained are shown in the accompanying table, JOHN L. WEBSTER
and demonstrate that an injection into an antecubital Sheffield