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i

Ultrasound Guided Regional Anesthesia

ii
iii

Ultrasound Guided
Regional Anesthesia
SECOND EDITION

Stuart A. Grant, MB, ChB

Professor of Anesthesiology
Duke University Medical Center
Durham, North Carolina

David B. Auyong, MD
Medical Director, Lindeman Ambulatory Surgery Center
Section Head, Orthopedic Anesthesiology
Virginia Mason Medical Center
Seattle, Washington

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2017

First Edition Published in 2012

Second Edition Published in 2017

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Grant, Stuart A., author. | Auyong, David B., author.
Title: Ultrasound guided regional anesthesia/​Stuart A. Grant, David B. Auyong.
Description: Second edition. | Oxford ; New York : Oxford University Press, [2016] | Includes bibliographical
references and index.
Identifiers: LCCN 2016005613 | ISBN 978–0–19–023180–4 (pbk. : alk. paper)
Subjects: | MESH: Anesthesia, Conduction—methods | Ultrasonography—methods
Classification: LCC RD84 | NLM WO 300 | DDC 617.9/​6 4—dc23
LC record available at http://​lccn.loc.gov/​2016005613

This material is not intended to be, and should not be considered, a substitute for medical or other professional
advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances.
And, while this material is designed to offer accurate information with respect to the subject matter covered and
to be current as of the time it was written, research and knowledge about medical and health issues is constantly
evolving and dose schedules for medications are being revised continually, with new side effects recognized and
accounted for regularly. Readers must therefore always check the product information and clinical procedures
with the most up-to-date published product information and data sheets provided by the manufacturers and the
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the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim,
any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or
application of any of the contents of this material.

9 8 7 6 5 4 3 2 1
Printed by WebCom, Inc., Canada
v

Preface

The foundations of this book come from the practical experience gained in performing and
teaching regional anesthesia techniques. Riding the initial waves of ultrasound guided regional
anesthesia, we reviewed many texts and other sources and found them to be lacking. Our
hope is to save the reader time and effort by sharing pearls and identifying pitfalls to set them
on a path for success.
This book differs from others of similar subject matter in that we have designed it as a
step-​by-​step practical companion. We succinctly lay down what we do and teach each day
in an organized fashion. There can be many approaches to any nerve block, and in the right
hands, many approaches can work. What we have conveyed are simple techniques based on
a thorough understanding of anatomy and our many years of clinical knowledge. This book
should provide all the necessary instruction to safely and accurately perform each nerve block
covered without an overwhelming amount of extraneous information.
In this second edition, we have refined the images that made the first edition so successful.
We have kept the format of clean, with unedited images next to colorfully annotated images
so the reader can compare the two side by side. In the few years since the first publication,
multiple additional ultrasound-​guided techniques have been described in the medical litera-
ture. As in the first edition, we have distilled these down to the most clinically successful and
practical approaches and added them to this new edition.
These specific nerve blocks are described in Chapter 2—​Upper Limb, Chapter 3—​Lower
Limb, and Chapter 4—​Trunk and Spine. Readers, whether novice or expert, should take time
to read Chapter 1. Chapter 1 is unique in that it covers the essentials of not just the “How
to Do It,” but the “How to Do It Well.” It contains many clinical pearls that can be useful
in performing any ultrasound-​guided procedure. A new appendix, “What Block for What
Surgery?,” is found at the end of Chapter 1. This addition will be useful as a practical guide for
clinical decision making.
It is beyond the scope of this book to be a comprehensive anatomy, physics, pharmacology,
and neurophysiology reference, and we refer readers to the ample texts already published
on these subjects. This book should be used as an everyday working practice guide to cover
the most common blocks and surgical procedures. Within the following pages, we repeatedly
convey the fact that there is no substitute for a good understanding of anatomy. As new blocks
are introduced, we head directly for our anatomy textbooks and the cadaver laboratory to
vi

vi
best understand how to make these new approaches work clinically. Fortunately, nothing has
changed in the anatomy book that you purchased as a student, so it remains your best com-
panion to supplement this textbook.
We are grateful to our families, friends, and colleagues for their patience and help during
the writing of this book and throughout our careers. We thank our contributors for their
enthusiasm and friendship. Lastly, we thank our teachers and mentors in the United States
and in Scotland for their guidance.

Stuart A. Grant
David B. Auyong
Preface
vii

vii

Acknowledgments

We would like to specifically thank Drs. Jim G. Benonis, Dara S. Breslin, and Jeff Gonzales for
their contributions to the first edition of this book. We would also like to thank Dr. Shin-​e Lin
for her time in reviewing this second edition for content and clarity.
viii
ix

ix

Contents

Chapter 1: Basic Principles of Ultrasound Guided

Nerve Block 1
Basic Ultrasound Physics and Ultrasound Machine Settings 3
How to Visualize Nerves and Needles 12
Common Artifacts and Errors 21
Positioning the Patient 26
Equipment and Preparation 28
Keys to Ultrasound Success 30
Principles of Peripheral Nerve Catheter Placement 35
Appendix: What Block for What Surgery? 39

Chapter 2: Upper Limb Ultrasound Guided

Regional Anesthesia 41
Interscalene Nerve Block 43
Suprascapular Nerve Block 61
Cervical Plexus Nerve Block 66
Supraclavicular Nerve Block 69
Infraclavicular Nerve Block 76
Axillary Nerve Block 83
Intercostobrachial Nerve Block 92
Nerve Blocks of the Elbow and Forearm 94

Chapter 3: Lower Limb Ultrasound Guided

Regional Anesthesia 105
Introduction 108
Femoral Nerve Block 111
Fascia Iliaca Block 121
Lateral Femoral Cutaneous Nerve Block 126
Adductor Canal Block (Selective Femoral Nerve Block) 129
Saphenous Nerve Block 137
x

x
Obturator Nerve Block 141
Posterior Lumbar Plexus Block (Psoas Compartment Block) 148
Sciatic Nerve Block 157
Anterior Sciatic Nerve Block 164
Popliteal Sciatic Nerve Block 167
Ankle Block 179

Chapter 4: Trunk and Spine Ultrasound Guided

Regional Anesthesia 187
Transversus Abdominis Plane Block 189
Quadratus Lumborum Block 198
Contents

Ilioinguinal-​Iliohypogastric Nerve Block 205

Rectus Sheath Nerve Block 210
Intercostal Nerve Blocks 214
PECS Block 222
Serratus Plane Block 226
Paravertebral Nerve Block 229
Neuraxial Anesthesia and Analgesia 241

Further Reading 255

Index 257
1

Chapter 1
Basic Principles of Ultrasound
Guided Nerve Block

Basic Ultrasound Physics and Ultrasound Machine Settings 3

Generation of Ultrasound Images 3
Transducer Selection 3
Frequency 4
Depth 5
Focus 6
Gain 6
Time Gain Compensation 7
Color Doppler Imaging 7
Clinical Case Scenario 10
How to Visualize Nerves and Needles 12
In-​Plane Needle Approach 12
Out-​of-​Plane Needle Approaches 13
Visualizing the Injection 18
Nerve Stimulation 18
Ideal Needle–Nerve Approximation for Regional Anesthesia 19
Common Artifacts and Errors 21
Dropout 21
Attenuation 21
Needle Sliver 21
Bayonet Effect 21
Intraneural Injection 21
Reverberation Artifact 22
2

2
Positioning the Patient 26
Equipment and Preparation 28
Needle Type and Length 28
Skin Preparation 28
Probe Cover 28
Monitoring 28
Sedation 28
1 Basic Principles

Time Out 29
Keys to Ultrasound Success 30
Principles of Peripheral Nerve Catheter Placement 35
Placement of Catheter 35
Confirming Local Anesthetic Spread 37
After Successful Catheter Placement 38
Appendix: What Block for What Surgery? 39

Ultrasound is revolutionizing regional anesthesia techniques that provide anesthesia and

postoperative analgesia for patients undergoing surgery. Almost every nerve block previ-
ously performed with the use of traditional localization techniques (paresthesias or nerve
stimulation) can now be performed under real-​time ultrasound guidance. New nerve block
approaches, such as the adductor canal nerve block, are not possible without ultrasound.
Unlike other localization techniques, ultrasound allows the visualization of nerves and sur-
rounding structures as well as the needle and the local anesthetic.
Ultrasound is most beneficial if a few basic concepts are understood.
3

3
Basic Ultrasound Physics and Ultrasound
Machine Settings
Generation of Ultrasound Images
The term ultrasound refers to high-​frequency waves produced by passing electricity through
piezoelectric elements. These elements vibrate at a high frequency, creating ultrasound
waves. The waves leave the ultrasound transducer and enter the body. They can then be
reflected, refracted, scattered, or absorbed depending on the internal structures they
encounter. The ultrasound transducer senses the reflected ultrasound waves, and ultra-

1 Basic Principles
sound images are generated from these reflected waves. Practically speaking, knowing that
ultrasound images show waves reflecting off structures in the body may help one to under-
stand why certain structures are visualized better than others. For example, a needle or
nerve that is perpendicular, or 90 degrees to the ultrasound wave, appears much brighter
on the ultrasound image than a needle or nerve at 45 degrees to the ultrasound wave
(Figure 1-​1).

Transducer Selection
Almost every nerve block and vascular access procedure can be performed with the use of
a linear, high-​frequency transducer. When considering a linear, high-​frequency transducer,
there are several options to choose from. First, linear probes come in varying sizes. For
regional anesthesia, appropriately sized linear probes are 25 to 50 mm wide (Figure 1-​2). The
smaller the probe, the more likely that it will fit into tight spaces on small patients. However,

Figure 1-​1 Reflections from structures are used to generate an ultrasound image. A structure that is perpen-
dicular to the beam (top) generates maximal reflection. A nerve or needle that is at a steep angle (bottom)
causes less reflection of sound waves to the probe.
4

4
1 Basic Principles

Figure 1-​2 Ultrasound transducers for regional anesthesia. A small linear probe (left) is used for tight areas
and vascular access; a large, high-​frequency linear probe (middle) for the majority of nerve blocks; and a large,
low-​frequency curvilinear probe (right) for deeper structures (e.g., neuraxial scanning).

small probes do not give a wide field of view, so it may more difficult to track a needle
approaching a target.
Second, each transducer has adjustable frequencies in a range that varies from 1 to
20 MHz. In general, the higher the frequency, the better the image quality, and the lower
the frequency, the better the penetration.
When choosing a transducer to perform a block, any linear probe that is able to generate
at least 9 MHz will suffice. We recommend using the widest probe available (appropriate for
patient size) to help with needle visualization and to allow visualization of surrounding tissue
structures (e.g., lung, blood vessels, muscles). High-​frequency linear probes are appropriate
for many blocks, including interscalene, supraclavicular, infraclavicular, axillary, femoral, pop-
liteal, sciatic, abdominal or chest wall, and adductor canal blocks.
Curvilinear transducers also come in different sizes. The curvilinear transducers are
lower in frequency, so they allow visualization of deeper structures. These transducers
are useful for imaging of the spine or paraspinous structures as well as the sciatic nerve.
Some curvilinear transducers give a wide field of view but have a large footprint. These
large, wide probes are very useful for sciatic and spine imaging (see Figure 1-​2). The smaller
curvilinear probes are useful for deep imaging and have a smaller footprint, permitting their
use in tight spaces.

Frequency
Each transducer has adjustable frequencies. At high frequencies, the trade-​off for better
image quality is poorer penetration (Figure 1-​3); at low frequencies, the trade-​off for better
penetration is poorer axial resolution due to the longer wavelength. The principle of axial
resolution means that two distinct points in the body, sitting in the same vertical axis, will be
delineated best on the ultrasound screen if a high-​frequency ultrasound beam is used.
For shallow blocks, it is best to use high frequencies, and for deeper blocks, it is best to use
lower frequencies. Instead of remembering the frequency numbers for each probe, some
5

1 Basic Principles
Figure 1-​3 To achieve the best axial (vertical) resolution, one should use the highest frequency possible. This
reduces the wavelength of the sound waves and makes discrimination of small structures possible. The trade-​
off is poor tissue penetration. The short-​wavelength, high-​frequency sound waves dissipate more energy,
leading to greater attenuation (i.e., less tissue penetration).

manufacturers have simplified frequency adjustments so that there are only three settings to
remember:
• General (Gen): General imaging frequency—​this is best for most blocks.
• Resolution (Res): High-​frequency imaging—​this is best for shallow blocks.
• Penetration (Pen): Low-​frequency imaging—​this is best for deep blocks.
For each probe, the image quality and penetration can be adjusted simply by using the Gen/​
Res/​Pen settings.
Each brand of ultrasound transducers provides for frequency adjustment in a different way.
Familiarity with the machine and learning to adjust the frequency result in improved imaging
with ultrasound.

Depth
The depth should be adjusted so the nerve target is in the middle of the screen. Most ultra-
sound machines are preset with the focal zones in the middle of the screen. Focus allows the
best possible axial resolution, improving image quality. This means that the clearest image
of the target will be obtained if the target is in the middle of the screen. A depth setting that
places the needle and nerve in the middle of the screen should be used whenever possible.
Some machines require manual adjustment of focal zones.
6

6
1 Basic Principles

Figure 1-​4 Focus position affects image quality. The identical interscalene anatomy is scanned on two images.
On the left, the focus is set deep, and on the right, the focus is set at the level of the targeted nerves. The
fascicles of the nerves are easier to identify on the right because the focus is set at the optimal depth for visu-
alization of the nerve roots at the interscalene level.

Focus
Ultrasound beams can be focused, much as light can be focused through a lens on a camera.
As in a photograph, ultrasound images that are out of focus appear less sharp. Correct focus
improves lateral resolution (Figure 1-​4). The principle of lateral resolution means that two dis-
tinct points in the body, sitting side by side, will be best delineated on the ultrasound screen
if correct focus is used.
Some machines have the ability to set focal zones and to move these zones up and down.
Focal zone markers usually appear as one to five small arrows on the side of the ultrasound
image. The focal zone should be set at the depth at which the nerve or target vessel is located.
Some machines have simplified the idea of focus and use a type of autofocus. With autofocus
machines, there are no focal zone markers; the focal zones are preset in the middle of the
screen. Therefore, the target should be placed in the middle of the screen by using the depth
buttons to optimize image focus.

Gain
The term gain on ultrasound machines refers to screen brightness. There are no specific rules
for adjusting the gain. Usually, each person has a preference for gain settings. However, some
general suggestions can be made.
• The brightness of the screen should be adjusted so that vascular structures appear dark or
anechoic (i.e., without echoes).
• Too much gain results in artifacts such as reverberation (discussed later); these artifacts can
“repeat” bright structures such as fascial planes, obscuring targets.
• Because ultrasound beams returning from deeper structures become attenuated (i.e.,
return a weaker signal), increasing the distal gain can be helpful in visualizing these struc-
tures (Figure 1-​5).
7

1 Basic Principles
Figure 1-​5 Overgained and undergained images. The center image demonstrates a bright radial nerve in the
center with good detail of the surrounding musculature. The undergained image of the same nerve (top) is very
dark, and the overgained image (bottom) is very bright. Vital detail is lost in both cases.

Time Gain Compensation

Time gain compensation (TGC) is the ability to adjust the gain (screen brightness) at several
levels on the ultrasound image. Some machines have sliding knobs to perform this task,
whereas others have dials to turn. Usually, the distal (bottom) part of the screen appears
darker than the proximal (top) part of the screen. In order to produce a more uniform
screen brightness, the TGC knobs should be increased distally and decreased proximally
(Figure 1- ​6).

Color Doppler Imaging

Color Doppler ultrasound imaging allows visualization of flow. Flow can be the movement
of arterial or venous blood or the movement of a local anesthetic into tissue after injection.
8

8
1 Basic Principles

Figure 1-​6 Time gain compensation (TGC) adjusts the brightness at various tissue depths on the screen.
This can lead to artifact if the adjustment bars (shown at left) are not set correctly. In the top image, the TGC
control bars are set appropriately and the nerves are visible. In the bottom image, one of the nerve roots is
not visible because the TGC bars controlling that region have been moved. Usually, the distal TGC levels are
set higher to compensate for attenuation.

It is important to remember that the red or blue color on the screen does not signify oxygen-
ated (arterial) blood or deoxygenated (venous) blood. A red appearance on color Doppler
imaging signifies that the fluid is moving toward the probe. A blue appearance means that the
fluid is moving away from the transducer. The mnemonic B.A.R.T. (Blue, Away from you; Red,
Toward you) may be used to remember this principle.
Sometimes, there is no color in a structure that appears to be a blood vessel. The Doppler
principle works best when the angle between the flow of the blood and the transducer is less
than 90 degrees. The Doppler equation uses the cosine of the angle between the transducer
and the flow, and the cosine of 90 is 0. This means that if the transducer is at 90 degrees to
the blood flow, the measured flow will be zero and there will be no color on the screen. The
transducer must be tilted in one direction or the other to better visualize blood flow with
color Doppler (Figure 1-​7 ).
When performing nerve blocks, it is often beneficial to move the Doppler box over not
only the large artery but also the path the needle will take toward the nerve. Moving the
Doppler box over the projected needle path before needle insertion helps identify smaller
vessels and prevent accidental vascular puncture.
9

1 Basic Principles
Figure 1-​7 Color Doppler ultrasound can help identify vessels. Tilting the probe can make vessels appear
to have better flow. This is important to help discriminate vessels from nerves. In the middle image, the
probe is placed perpendicular to the direction of blood flow, resulting in limited Doppler signal. In the
upper image of the same artery, the probe is tilted at an acute angle, producing a better Doppler signal.
The lower image identifies the structures shown.
10

10
Clinical Case Scenario
The following clinical case example is provided to illustrate the importance of understanding
the ultrasound controls. When reading through this scenario, practitioners are encouraged
to reflect on how they utilize the ultrasound controls or move the ultrasound transducer.
A patient weighing 300 lb (136 kg) is scheduled to undergo complex ankle and foot surgery.
The anesthetic plan is a popliteal nerve block and an adductor canal block.
After all equipment has been gathered, the consent has been obtained, the patient has been
positioned and sedated, and the anesthesia time out (discussed later) has been performed,
it is time to begin the procedure. The ultrasound machine should be positioned so that the
1 Basic Principles

operator can easily see the screen by simply gazing upward.

After the ultrasound machine is powered up, it will default to its usual startup settings. At
our institution, with a high-​frequency linear probe, the default depth is 2.5 cm and the default
frequency setting is “Res” (resolution). In this obese patient, the popliteal artery will not be
visible at these default settings. As most practitioners will recognize, an increase in depth
is warranted. If the target structure is at a depth of 4 cm but the screen is set at a depth of
2.5 cm, the depth setting must be increased to view the target.
Does increasing the depth setting improve the imaging of structures deeper in the image?
Sometimes a structure is so obvious that an increase in depth will help visualize the target.
However, increasing the depth alone often does not make deeper structures visible because
the deeper part of the image appears darker. Three additional aspects besides depth must be
considered: frequency, gain, and focus.
Frequency does not change when depth is increased. Increasing the depth alone does not
improve the ability of the sound waves to penetrate into the tissues. Frequency and depth
are not linked on the ultrasound machine. To improve the visibility of deeper structures, the
frequency range should be reduced. It is vital to understand how to do this on the specific
ultrasound machine being used. Some machines require dial adjustments with a specific fre-
quency number, whereas others provide nomenclature delineating a frequency range (i.e.,
Resolution, General, and Penetration). Decreasing the frequency can reduce the resolution
of fine detail, but if this adjustment allows the target structure to appear more obvious, it is a
trade-​off that can be tolerated. If increasing the depth and lowering the frequency is still not
enough, changing the transducer to one with an even lower frequency can be a feasible step.
This is one reason why a prescan or scout scan is good practice.
The second important adjustment is gain (image brightness). When the image depth is shal-
low, brightness often looks uniform. If the depth is increased, it becomes much more obvi-
ous that gain is not uniform. The deeper parts of the image appear much darker because of
attenuation (scattering and absorption of ultrasound waves). The operator can increase the
overall gain, which allows the deeper target area to be better visualized, but often at the cost
of loss of detail in the superficial structures because they are now too bright. Almost all ultra-
sound machines have a TGC capability, which allows the operator to adjust the brightness at
multiple levels from superficial to deep. Some machines allow TGC adjustments in two areas
(i.e., proximal and distal); others have multiple TGC controls to allow adjustments in up to
eight different levels. Learning where the gain controls are and how to use them is important
to improve imaging in challenging patients.
Finally, the focus of the ultrasound machine is important. Focus helps improve the resolu-
tion of the image. In some popular machines, the focus is always in the middle of the ultra-
sound image. For example, if the depth is set at 2 cm, the focus will be at 1 cm; if the depth is
11

11
set at 6 cm, the focus will be closer to 3 cm. A machine with independent focus controls often
permits a change in focal depth and in the number of focal zones. A change of focus position
can improve image quality. It must be understood that depth adjustments do not change fre-
quency, but a change in depth can change the focus.
To summarize, one should first change the depth setting, then consider (1) lowering the
frequency, (2) adjusting the gain, and (3) adjusting the focus position.
Once the nerve is visible, the operator should consider techniques to improve needle
imaging. Most important for imaging of the needle is the insertion point of needle entry.
The depth of the target structure should be determined, and the operator should plan to

1 Basic Principles
insert the needle sufficiently far from the transducer so that it can be advanced at a flat angle
(<30 degrees if possible). Even for a shallow block in which the target is less than 2 cm deep,
plan to start the needle about 1 cm away from the transducer. For deeper blocks at 4 to 5 cm,
consider inserting the needle up to 5 cm away from the transducer (Figure 1-​8).
Another adjustment to improve needle imaging is to ensure that there is a marked heel-​
toe tilt of the transducer away from the point of needle entry (see later discussion). This
movement is particularly important in obese patients, in whom the needle trajectory can be
very steep. Steep needle trajectories make needle imaging difficult, and a heel-​toe tilt can
decrease the perceived steepness, resulting in improved needle brightness. The following
section describes a step-​by-​step process for needle visualization.

Figure 1-​8 Adjusting the needle insertion site. Two examples of an adductor canal block are shown: a shallow
nerve target at 1.5 cm (left) and a deeper nerve target at about 3 cm (right). To perform a nerve block with a
shallow target, the needle should be inserted 1 to 2 cm lateral to the transducer. To perform a nerve block
for a deeper target, the needle insertion site may be 3 to 4 cm lateral to the probe. Starting the needle inser-
tion farther from the probe for deeper blocks allows for a flat needle angle that better reflects the ultrasound
waves. This results in better needle visibility during the nerve block. A, artery; N, nerve; V, vein.
12

12
How to Visualize Nerves and Needles
The term axis in ultrasound guided regional anesthesia is used to describe the view obtained
of a structure (nerve or vessel) in relation to the ultrasound beam. A long axis view is an image
along the length of the nerve. A short axis view cuts across the diameter of the nerve. Usually,
the goal is to obtain a short axis view of the nerve.
The term plane in ultrasound guided regional anesthesia is used to describe the needle
position relative to the ultrasound beam. Most nerve blocks are performed with an in-​plane
approach (see later discussion). If performed correctly, this approach allows the entire nee-
1 Basic Principles

dle (shaft and tip) to be visualized (Figure 1-​9). As a result, the user can place the needle
tip with the greatest amount of confidence and, potentially, the greatest safety. Out-​of-​plane
approaches, if done correctly, can also be an effective way of targeting nerves or vessels with
needles. Both techniques have risks and benefits, and the practitioner must decide which
needle approach is suitable for each block or target.

In-​Plane Needle Approach

A Three-​Step Process for In-​Plane Needle Imaging
The following three-​step process should be performed in the order shown to quickly locate
and image the needle in-​plane.
1. Step 1: Look at Your Hands. Look down at your hands and physically line up the trans-
ducer with the needle. Aligning the needle and transducer for in-​plane imaging is difficult
when looking at the image on the ultrasound screen. The quickest way to align the probe
and the needle is to take your eyes off of the ultrasound screen and look down at your
hands to physically line up the needle with the exact center of the transducer (Figure 1-​10).
The center of the probe and the needle must be in exact alignment to produce a needle
image. Spending a few seconds to ensure that the needle and transducer are in perfect
alignment by physically looking at your hands holding the needle and transducer can most
efficiently improve needle visualization under ultrasound.

Figure 1-​9 In-​plane and out-​of-​plane needle approaches. The upper images demonstrate an in-​plane needle
approach with needle-​probe alignment in space (upper left), needle-​probe on a mannequin (upper middle),
and ultrasound image of an in-​plane needle (upper right). The lower images demonstrate an out-​of-​plane
needle approach with needle-​probe alignment in space (lower left), needle-​probe on a mannequin (lower
middle), and ultrasound image of an out-​of-​plane needle (lower right).
13

13

1 Basic Principles
Figure 1-​10 Step 1: Look at Your Hands. To most quickly find a needle, look at your hands, the needle,
and the probe (left). Spend some time to physically line up the probe and the needle before looking up at the
ultrasound screen (right). A common beginner’s mistake is to try to align the needle by looking only at the
ultrasound screen. Look down at your hands first. Once the needle and probe are grossly aligned, only slight
probe movements will be required to image the needle brightly.

2. Step 2: Slide to See the Needle. Slide the probe back and forth across the needle to visu-
alize the needle on the ultrasound screen. If the needle has been properly aligned (Step 1),
the next step is to slide the transducer across the needle (Figure 1-​11). Sliding is much
more effective than other transducer movements (e.g., tilt, rotation, pressure) in finding
the needle. If the needle and probe are in exact alignment, the most effective way to visual-
ize the needle with ultrasound is to slide the probe only a few millimeters back-​and-​forth
across the needle because the needle must cross the path of the ultrasound beam with this
movement. Sliding also helps to maintain good visualization of the target structures during
needle advancement.
3. Step 3: Heel-​Toe the Ultrasound Beam into the Needle. Aim the ultrasound
beam into the needle with a heel-​toe transducer movement. If the needle is still not visible
after Steps 1 and 2, heel-​toe the probe by moving the top of the transducer away from the
needle entry point. This orients the ultrasound beam coming from transducer more to
the position of the needle, which in turn improves reflection of the ultrasound waves from
the needle, enhancing needle brightness on the ultrasound image (Figure 1-​12).
Needle visualization with an in-​plane approach is not easy, but following the steps in this sec-
tion will greatly increase success. In addition, practicing the technique as described improves
the time required to perform regional anesthesia at the bedside. The three-​step process for
in-​plane needle visualization can be practiced in a gel phantom or a piece of meat obtained
from the grocery store. Out-​of-​plane needling technique is described next and can also be
practiced in the same manner.

Out-​of-​Plane Needle Approaches

Out-​of-​plane needle approaches most closely resemble the needle approaches that were
used when paresthesia or nerve stimulation was the means of locating nerves. Some people
prefer out-​of-​plane needle approaches because they are more comfortable with the tra-
ditional approaches to locate nerves. However, out-​of-​plane nerve blocks do not visualize
the tip of the needle at all times and therefore do not offer the same level of confidence and
potential safety that comes with always knowing where the needle tip is located. Out-​of-​plane
needling techniques are particularly useful for vascular access procedures and deep nerve
blocks.
14

14
1 Basic Principles

Figure 1-​11 Step 2: Slide to See the Needle. Once the needle is physically aligned as described in Step
1, only slight sliding of the probe back and forth across the needle will be required in most cases to image the
needle (right images). Although tilting the probe is useful for improving the imaging of nerves (left images), tilting
the probe to find the needle will degrade the image of the target structures. This can be summarized in the
statement, “Tilt to see nerves, slide to see needles.”

An out-​of-​plane approach to needle insertion appears simple but can be difficult. The
major fault with these approaches is that the needle appears as a hyperechoic or bright dot
on the ultrasound screen. This bright dot can be the tip of the needle (and is often assumed
to be the tip of the needle even when it is not), but it can also be the shaft of the needle.
Assuming that the hyperechoic dot on the screen is the needle tip is a common beginner’s
mistake. In an out-​of-​plane approach, the shaft of the needle looks no different from the tip,
but the tip may actually be much deeper in the tissues. Another fault is that the dot of the
needle sometimes is not visible at all. As with in-​plane needle advancement, needles inserted
at shallow angles will appear brighter on the ultrasound image. Therefore, a flat needle angle
should be used for insertion in the out-​of-​plane needle orientation whenever possible. The
15

15

1 Basic Principles
Figure 1-​12 Step 3: Heel-​Toe the Ultrasound Beam into the Needle. Aim the ultrasound beam into
the needle to image needles inserted at steep angles. Often just a small angling of the probe into the needle
allows for significantly improved needle visualization. The top images were obtained with the probe oriented
vertically; in the bottom images, the probe is tilted. The images at left and middle were done with the use
of a gel phantom and illustrating the improved needle visualization when the ultrasound beam is angled into
the needle. This is highlighted in a clinical adductor canal block, where needle imaging is improved using this
technique (right images).

dot on the screen will appear much brighter because of improved ultrasound reflection from
the needle.
Good out-​of-​plane needle technique follows the tip of the needle as it is advanced through
tissue. Three techniques are used to follow the needle tip.
Out- ​of- ​Plane Technique 1—​Slide the Probe
The needle is advanced out-​of-​plane until a bright dot is visualized above (i.e., shallow to)
the target (Figure 1-​13). Once this dot is visualized, needle movement stops. The probe is
then advanced forward (away from the needle) until the dot disappears. Next, the needle is
advanced again until the dot reappears; it should now be deeper and closer to the target. The
probe is then advanced until the dot disappears again. The needle is then re-​advanced. These
steps are repeated until the dot is near the target. The dot must appear and disappear as the
needle and the probe are alternately advanced. This way, the tip is confirmed as it approaches
the nerve or vessel target.
Out-​of-​Plane Technique 2 –​Tilt the Probe
This technique is similar to the sliding technique, but it allows the probe to stay in one spot and
may be useful in tighter areas where the probe cannot slide very far (Figure 1-​14). The needle is
advanced out-​of-​plane until a bright dot is visualized above (shallow to) the target. Once this dot
is visualized, needle movement stops. The ultrasound beam is then tilted forward (away from the
needle) until the dot disappears. The needle is then advanced until the dot reappears. The dot
should now be deeper and closer to the target. The ultrasound beam is again tilted forward until
the dot disappears. The needle is then re-​advanced. This process is repeated until the dot is near
the target. Essentially, the dot must appear and disappear as the needle and probe are alternately
moved. This way, the tip is confirmed as it approaches the nerve or vessel target. This technique
is better for vessels than for nerves; nerves often disappear if the probe is tilted too much.
16

16
1 Basic Principles

Figure 1-​13 Out-​of-​Plane Technique 1—​Slide the Probe. Hold to probe over the target. Advance the
needle slowly in a shallow plane with the bevel up (to make the needle most visible). Look carefully for the
hyperechoic dot as the needle cuts the plane of the beam, then stop advancing the needle immediately (top
images). Slide the probe forward beyond the needle tip. Increase the needle angle appropriately, and advance
the needle again, looking carefully for the hyperechoic tip. Stop as soon as the needle tip is visible (middle
images). Repeat the process until the needle descends down onto the target (bottom images).

Out-​of-​Plane Technique 3—​Adjust the Needle

This technique allows the probe to remain completely stationary. The needle is advanced
out-​of-​plane until a bright dot is visualized above (shallow to) the target. Once this dot is
visualized, needle advancement stops. The needle is then withdrawn (but not completely out
of the body), and the dot should disappear. The needle angle is steepened, and the needle
is advanced again until the dot reappears (Figure 1-​15). The dot should now be deeper and
closer to the target. The needle is again pulled back, making the dot disappear, then re-​
advanced at a yet steeper angle. This process is repeated until the dot works deeper and is
17

17

1 Basic Principles
Figure 1-​14 Out-​of-​Plane Technique 2—​Tilt the Probe. Hold the probe over the target with the probe
tilted so that the ultrasound beam faces the needle. This increases the reflection from the needle and provides
room to tilt the probe toward the needle as it is advanced. Advance the needle slowly in a shallow plane with
the bevel up. Look carefully for the hyperechoic dot as the needle tip appears on the screen. As soon as the nee-
dle is visible, stop advancing immediately (top images). Tilt the probe to ensure that the ultrasound plane is just
beyond the tip of the needle. Next, advance the needle toward the target. Again, as soon as the needle breaks
the plane of the beam, stop (middle images). Repeat the process until the target is reached (bottom images).

near the target. Essentially, the dot must appear and disappear as the needle is advanced and
withdrawn. This way, the tip is confirmed as it approaches the nerve or vessel target.
All of these techniques require one important quality when looking for the bright (hyper-
echoic) dot of the needle: the bright dot must appear, then disappear, then appear again as
the needle is advanced through the tissue. If the dot does not disappear, there is no way to
rigorously confirm that the dot is the needle tip.
18

18
1 Basic Principles

Figure 1-​15 Out-​of-​Plane Technique 3—​Adjust the Needle. Hold the probe over the target. Advance
the needle under the middle of the probe with a shallow insertion angle. When the tip of the needle appears
visible as a bright dot on the screen, immediately stop needle advancement (top images). Withdraw the nee-
dle, and redirect it at a steeper angle. Advance the needle until the tip is seen, and stop again (middle images).
Repeat the process at steeper angles until the target is reached (bottom images). The hyperechoic tip can be
viewed in a stepwise fashion as it descends toward the target.

Visualizing the Injection

Probably the best marker for ruling out intravascular injection of local anesthetic is ultra-
sound visualization of the injectate. If local anesthetic spread is not obvious on the ultrasound
screen, the injection should immediately be halted and the needle tip position reconfirmed.
It should be assumed that the needle tip is intravascular if no spread of the local anesthetic is
visualized.

Nerve Stimulation
Nerve stimulation is a good way to confirm that a nerve has been reached when using
ultrasound. Many centers routinely use nerve stimulation in conjunction with ultrasound.
Another Random Scribd Document
with Unrelated Content
"I've heard your aunt say half-a-dozen times that she did
not like your going to those Burnsides," said the farmer.

Steenie laughed and shrugged his shoulders. "I'm not

bound to care for all her likes or dislikes either," muttered
the boy, tapping his front teeth with his silver-tipped cane.

Macalpine's sharp keen eyes looked sharper and keener

than ever as he observed, "After your aunt's bringing you
up, and doing everything for you these ten years, ever since
you could toddle alone, I think that she has a good claim at
least to your obedience, if you have no affection to give."

Apparently Master Steenie did not relish his uncle's remark,

for, perhaps to turn the conversation, he began teasing the
farmer's dog. Macalpine's angry remonstrance led to the
reply of his nephew with which my little story begins.

"I wonder that you care to keep such a rough ugly cur as
that Trusty," observed Steenie Steers.

"I keep him for some use," answered the farmer. "Trusty
guards my flock attends to my call; by day or by night; in
snow, rain, or hail, he is always ready to do my bidding.
He's a good old fellow," continued Macalpine, stooping to
pat his rugged friend, who licked the farmer's hand in
return. "I've reared him from a puppy."

"I should not care to rear such a common kind of dog as

that," observed Steenie, who prided himself on being a dog-
fancier. "If he were a King Charles spaniel now—"

"Or a pug or a poodle," interrupted the farmer; "I should

not consider him worth the rearing. I care for use, not for
show."
"Your favourite does not cost you much, I'll be bound!" said
Steenie Steers, with a saucy laugh.

"Trusty costs me nothing," answered Macalpine, "for he is

content with a few bones, and fairly earns what he gets. But
a friend of mine once reared a puppy that would, perhaps,
be a puppy just to your taste. Plenty of care and pains she
bestowed on the useless creature, and stuffed it with food
more than enough. I consider that much of that good
feeding was downright waste, seeing what the puppy was to
turn out, and that my poor friend really stinted herself to
pamper her pet."

"Did the creature devour so much, then?" inquired young

Steers.

"Why, he must have gobbled up, during his training,—let me

see—let me see," and Macalpine rubbed his shaggy head to
help out his calculations,—"the pet must have gobbled up as
good as three hundred big legs of mutton!"

"I say!" exclaimed Steenie, in much amazement. "Your

friend's pet must have been no pup, but a lion, and one
with a monstrous appetite, too! Such a brute as that would
soon eat his mistress out of house and home."

"He did not eat all the mutton in a day—or a week—or a

month; he took his time about it," said the farmer, with a
low chuckling laugh. "But my friend's hungry pet did not live
on mutton alone; we must add to the meat some three
hundred pounds of fresh butter!"

"A dainty dog!" exclaimed Steenie.

"And not much less than a thousand loaves of white bread,"

said Macalpine "with tubs of milk, and casks of beer, and I
don't know how many plum-cakes, seed-cakes, iced cakes,
and all sorts of sweeties besides!"

"You are cracking a joke on me, uncle," said Steenie. "I'll

answer for it that your friend's pet was never a puppy at
all."

"I could not answer for it that he is not one now, and a very
useless puppy, and a very ungrateful puppy," cried the
farmer, rising from his seat. "There, I see my sister
coming," he added, as he looked through the open door-
way; "Trusty, you and I will go and meet her."

Trusty, ever ready, sprang up and followed his master.

Steenie's face had grown exceedingly red at the words of

Macalpine; the boy bit hard the silver tip of his cane. He
could now see clearly enough what his uncle's meaning had
been. Steenie himself was the idle, ungrateful puppy, that,
after having been fed for ten long years on his kind aunt's
bounty, had made no kind of return for all the care and love
which she had lavished upon him.

I must say that Farmer Macalpine had a rude and

disagreeable way of giving reproof; he did not, as all
Christians ought to do, speak the truth in love. His manners
and his words were as rough as his hair. We may have no
such plain-spoken uncle to remind us of things which we do
not care to remember, but it is well for all who have been
brought up by parents or friends in comfortable homes, all
who have been fed and clothed year after year by the
kindness of others, to ask themselves what return they are
making for all that they have received.

I fear that Steenie Steers is not the only boy who deserves
the name of "a very useless puppy," and who might, if he
would, learn a lesson from Trusty, the old shepherd's dog.
 What Bird Would You Be?

"A NEW game for a rainy day!" cried Clara, clapping her
hands to command silence amongst the merry little group
of children who, tired of active romps, now clustered around
her.

"It must be a quiet one, for the little ones are out of breath
with Blindman's Buff, and Sophy, I see, is fanning herself on
the sofa. Here, Tom and Felix, draw in chairs to form a
circle; the two footstools will do nicely for Jessie and Minnie
—little seats will suit little people. Tall Phil, you may perch
on the music-stool, and look down on us all, if you like it."

The circle of children was soon formed, all waiting till Clara
should tell them how to begin their new game.

Clara took a rich red rose from a vase which stood near. "I
am going to ask a question," said she, "and to the one who
shall offer the best reason for his or her answer, the rose
shall be given as a prize."

Tom, a merry rosy-cheeked boy, laughed as he stooped and

whispered to his next neighbour, Annie. "If the rose were to
be won by giving a long jump, or a hard pull, or a good
knockdown blow, I'd have a chance," said he; "but you
could wring out butter from a broom-stick sooner than a
rhyme or a reason from me."

"Let's hear the question," cried Phil.

"If you were to be changed into a bird, what bird would you
choose to become?" asked Clara.

"An eagle," shouted out Master Tom.

"Your reason?" inquired the young lady.

"Well," drawled out the boy, "suppose because he is the

biggest and strongest of birds, and able to whack all the
rest."

"The eagle is neither the biggest nor the strongest of birds,"

cried Phil. "The ostrich, condor, and albatross are all larger,
and some more powerful than the eagle."

Tom shrugged his shoulders and shook his head; had he not
been fonder of boxing than of books, he might have said
that the huge condor, being a vulture, is of the same order,
and therefore may be called first cousin to the eagle.

"Jessie, dear, what would you be?" asked Clara of the

smallest child in the room.

"I'd be a hummingbird," lisped Jessie, "'cause it's the

prettiest of all 'ittle birds."

"Pretty, yes," observed Annie, her sister; "but I think that

its prettiness is rather an evil to it than a good. If you were
a hummingbird, Jessie, you would very likely be caught,
killed, and stuffed for the sake of your beauty."

"And what says our little Minnie?" inquired Clara of a plump,

fair, flaxen-haired child who sat on a footstool next to
Jessie, with her arm round her young companion.

"I'd be a beauty swan, swimming about amongst the lilies,

under the shady trees," said the child, who had admired the
swan and his mate, with their little cygnets, floating on the
lake, as she had seen them that morning.

"Give us your reason," said Clara.

"I like paddling about in the water, it's so nice," was the
simple reply.

"Ay, you would like it in summer," cried Phil, "when the lilies
are in flower, and the trees in leaf. But I know a little lady
who in winter does not care to stir off the hearth-rug, and is
ready to cry if sent out into the cold. She would not then
care to be a swan, and paddle about on the ice."

"I'd rather be a swallow," cried Felix, "and escape altogether

from winter with its frosts and its snows. A life of active
pleasure, not of lazy enjoyment, for me! I like to travel and
see distant lands and what fun it would be just to spread
one's wings and be off for France, Italy, or Algiers, without
any trouble of packing a trunk, with nothing heavier to
carry than feathers, and no railway tickets to pay for, or bills
at hotels on the way!"

"Were you a swallow, you'd have a bill wherever you flew,"

laughed Phil.

"Oh! A precious light one," said Felix gaily.

"As for me, I'd prefer the life of a lark," cried Phil. "I'd
sooner mount high than fly far; and I'd like to whistle my
song from the clouds. To my mind, the little sky-lark is the
merriest bird under the sun."

"If you were to be changed into a bird, Sophy, what bird

would you be?" asked Clara of a rather affected little girl,
who sat twirling the bead bracelet which she wore on her
arm.
Sophy drooped her head a little on one side, as if it rather
troubled her to give an opinion,—and she thought herself
too much of a fine lady to join in so childish a game. She
glanced up, however, at the splendid rose which Clara held
in her hand, and thinking that it would look very pretty in
her own hair, prepared to answer the question.

"What bird would you be?" repeated the boys, who were
growing a little impatient.

"The nightingale," said Sophy in an affected tone, again

looking down, and twirling her beads.

"You must give your reason for your choice," observed

Clara.

"Every one admires the nightingale's sweet notes," said

Sophy, glancing up at the rose.

"Oh, ho! There's a fine reason!" laughed Phil. "I'd sing like
the lark in the joy of my heart, with the sunshine about me;
but Sophy would sing for other folk to admire her trills and
her shakes, and cry out, 'I never heard anything so fine!'"

Sophy looked vexed at the remark, for Phil had hit on her
weakness; the vanity which is always seeking for praise.
Clara, who liked all to be peace and good-humour, turned at
once the attention of the little party in another direction, by
addressing Annie, the only one of the circle who had not yet
been questioned.

"What bird would you be, dear?" asked she.

"I think, an eider-duck," replied Annie.

Her answer was received with a burst of laughter.

"A duck—to dabble in mud, and gobble up snails and frogs!"
cried Phil.

"Or be gobbled up itself, with green pease, and admired as

a very nice bird!" exclaimed Felix.

"Ducks are very pretty—almost as pretty as swans," lisped

little Jessie, who did not like her sister to be laughed at.

"I do not think that eider-ducks are pretty," said Annie; "I
did not choose the bird for its beauty."

"You have not given us a reason for your choice yet,"

observed Clara.

"I think the eider-ducks useful," said Annie; "the delightful

quilt, so light yet so warm, which has been such a comfort
to mamma in her illness, was made from their down. But
my chief reason for liking the bird is its unselfishness. You
remember, Jessie," added Annie, addressing her sister,
"what mamma told us about the eider-ducks that are found
in Scotland, Norway, and Iceland?"

"Oh yes; I know all about them!" cried Jessie. "The good
mother duck pulls off the down from her own breast to line
her nest, and make it soft and warm for her baby ducklings;
and when people steal away the down, she pulls more and
more, till she leaves herself bare,—and then her husband,
the drake, gives his nice down to help her."

"When mamma told me all this," said Annie, "it reminded

me of the beautiful story of the Highland mother who was
overtaken by a terrible snowstorm, as she travelled with her
babe in her arms. The mother stripped off her shawl, as the
duck does her down, and wrapped it close—oh, so close!—
round her child, and hid him in a cleft in a rock. The baby,
wrapped in his mother's shawl, was found alive where she
had left him; but the poor woman—the loving woman—"
Annie's voice failed her, and she did not finish the touching
tale of the mother who perished in the cold from which she
had guarded her child.

"Now let us compare the various reasons which have been

given for choosing different birds," said Clara, "that we may
decide upon which is the best one. The eagle was chosen
for size and strength, the little hummingbird for beauty; one
liked the swan's life of easy enjoyment, another the
swallow's of active amusement. The lark was chosen for
cheerfulness, the nightingale for the admiration which he
gains, the eider-duck for the unselfishness which she
shows. Now which of our little party has given the best
reason for a choice?"

"Annie! Annie!" cried most of the children—though Sophy

murmured something about "an ugly waddling creature that
can say nothing but 'quack!'"

"Then I think that we agree that Annie has won the rose,"
said Clara.

And if, before the day was over, that sweet rose found its
way to a chamber of sickness, and was laid on an eider-
down quilt within reach of a lady's thin hand, the reader will
easily guess how it came there. Annie was one not only to
admire but to imitate the unselfishness of the bird that finds
its pleasure in caring for the comfort of others, instead of
seeking its own.
 The Hero and the Heroine.

"HARRY was a hero, if ever there was one!" cried Theodore

Vassy, after he had been for some time silently looking at a
print of the prince who was afterwards so famous as Henry
V. The print represented the well-known anecdote of Harry's
trying on the crown of England by the sick-bed of his father.

"I never admire that story much," observed Theodore's

eldest sister Alice, raising her eyes from a volume which she
had been reading. "A son finds, as he thinks, that his father
has just died; and, instead of bursting into tears (like our
good Queen when she gained a throne by the death of her
uncle), Prince Harry's first thought is to try on the crown! I
do not wonder," added Alice with a smile, "that when the
poor sick king woke from his deathlike sleep, he was little
pleased with his son."

"But the son, if the story be true, made such a noble excuse
for himself, that even his father was satisfied," said
Theodore. "Harry had not tried on the crown because he
was in the least hurry to wear it, but because—"

Alice shook her head, laughing. "Harry's excuses may have

been clever, but I am afraid that they were but false ones,"
said she; "for when he was once on the throne, one crown
was not enough for King Harry: he must carry sword and
fire into poor France, because he wanted to have two!"

"Girls know nothing, understand nothing, about heroes,"

said Theodore in a tone of contempt.

"Girls have been heroines," replied Alice with some

animation. "In this very book which I have been reading
—'Memorials of Agnes Jones'—there is an anecdote of her
courage when she was a child of but eight years old which
might have done credit to a boy of ten, even if he bore the
name of Theodore Vassy," added the elder sister gaily.

Theodore prided himself on his manly spirit, though it was a

spirit which more often carried him into difficulties than
bore him bravely through them. For instance, Theodore had
boasted that he would clear his father's cellar of the
troublesome rats that had made it their home; and he had
made an attempt to do so. The boy had even succeeded in
catching a rat by the tail! But no sooner had the fierce little
prisoner turned and bit his captor's finger, than Theodore,
giving a cry of pain, had let the rat go, and had retreated at
once from the cellar, leaving the honours of the battle-field
to his small four footed foe.

Luckily for Theodore, no one had been present to witness

the fight; and the boy took good care not to mention his
adventure. Not even Alice knew where her brother had got
the little mark left on his hand by the teeth of the rat.

"Let's hear your anecdote, if it's worth the hearing," said

Theodore Vassy. "I never yet knew a girl who would not cry
at the prick of a needle."

Alice turned back the pages of the book which she had been
reading, till she came to the part relating to the childhood of
Agnes Jones.

"This memoir is written by the sister of Agnes," observed

Alice; "and it is one of the most beautiful books which I
ever read in my life."

"And who was this Agnes?" asked Theodore.

"A young lady, the daughter of an officer," replied Alice
Vassy. "When she was a little child, she accompanied her
parents to the island of Mauritius, off the east coast of
Africa, where occurred the following incident, thus related
by her sister." And Alice read as follows:—

"At Mauritius, when she was about eight years old, a friend
sent her a present of a young kangaroo from Australia. An
enclosure was made for it in the garden, and Agnes
delighted to feed and visit it daily."

"I've seen a kangaroo in the Zoological Gardens,"

interrupted Theodore. "It was larger than our big dog, and
went springing and jumping on its long hind legs, as if it
were set on springs. I never saw such a creature for
leaping! I was told that the kangaroo has tremendous
strength in those hind legs, and that, when hunted, it
makes itself dangerous even to the dogs. I suppose that
this little girl's kangaroo was very tame as well as young, or
she might have had more pain than pleasure from her
plaything." Theodore was thinking of his fight with the rat.

Alice went on reading the sister's account of the little Agnes

and her pet kangaroo:—

"One day, as she opened the gate, it escaped, and bounded

off into our neighbour's plantation. Agnes followed, fearing
it might do mischief, climbed over the low wall which
separated the two gardens, and after a long chase
succeeded in capturing the fugitive. Some minutes
afterwards my mother came into the garden, and was
horror-struck to see her returning from the pursuit—the
kangaroo, which she held bravely by its ears, struggling
wildly for freedom, and tearing at her with its hind feet;
while her dress was streaming with blood from the wounds
inflicted by its nails."
"I say!" exclaimed Theodore involuntarily, "I'd have let the
horrid beast go!"

"But she would not do so," continued Alice, still reading,

"until she got it safely into its house; although it was many
a long day before she lost the marks of her battle and its
victory."

"She was a gallant little soul!" exclaimed Theodore. "What a

pity it is that Agnes was a girl, and not a boy! For, after all,
courage is not of much use to a woman."

"I am not sure of that," replied Alice; "nor, perhaps, would

you think so, were you to read this beautiful Life. Agnes left
a bright, happy home, to watch as a nurse by the sick-beds
of the poor. Though she was a lady born and bred, she
shrank from no drudgery, grumbled at no hardship: she
worked hard, and she worked cheerfully, looking for no
reward upon earth. Agnes had to struggle against great
difficulties; but she mastered them just as she had
mastered the kangaroo when she was a child."

"And got nothing by it," said Theodore Vassy. "One might

suffer, and struggle, and conquer difficulties, if, like Harry
the Fifth, one had a crown to make it worth while."

"There was a crown for Agnes," observed Alice gravely; "but

not one that man could give, or that she could wear upon
earth. The artist who drew that picture—" Alice glanced as
she spoke at the print in the hand of her brother—"has
made Prince Henry look upwards, as if praying to be made
worthy to have a crown. Agnes Jones's was a life-long
looking upwards—a life-long trying on, as it were, of the
crown prepared for such as love their Heavenly King;—and I
believe," added Alice, as she closed her volume, "that after
her brave struggles and her victories, Agnes Jones has gone
to wear that crown."

Beware of the Wolf.

YOU never need fear, little children, to meet

A wolf in the garden, the wood, or the street;
Red Riding-hood's story is only a fable,—
I'll give you its moral as well as I'm able:
Bad Temper's the wolf which we meet everywhere—
Beware of this wolf! Little children, beware!

I know of a boy, neither gentle nor wise,

If you tell him a fault, he gives saucy replies;
If kept from his way, in a fury he flies—
Ah! Passion's the wolf with the very large eyes;
'Tis ready to snap and to trample and tear—
Beware of this wolf! Little children, beware!

I know of a girl always trying to learn

About things with which she should have no concern:
Such mean Curiosity really appears
To me like the wolf with the very large ears,
All pricked up to listen, each secret to share—
Beware of this wolf! Little children, beware!

And Greediness, that's like the wolf in the wood

With the very large mouth, ever prowling for food,
That eats so much more than for health can be good;
That would clear a whole pastry-cook's shop if it could;
That never a dainty to others will spare—
Beware of this wolf! Little children, beware!

PASSION, PRYING, and GREEDINESS, each thus appears

As a wolf with fierce eyes, a large mouth, or big ears;
They bring to our nurseries fighting and fears,
They cause bitter quarrelling, trouble, and tears.
Oh! Chase them and cudgel them back to their lair—
Beware of the wolves! Little children, beware!
 *** END OF THE PROJECT GUTENBERG EBOOK THE
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