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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.
Another Random Scribd Document
with Unrelated Content
 298 3* Pattern: sentence 5» a» I heard that you did not
stay in Delhi* b. I heard that you had gone to Delhi* c* I heard that
you also went to Bengal* d* I heard that you had lived in a village
before* e* I heard that you had bought a new car* 4* Pattern:
sentence 4* a* Yes* Even though I live in Delhi, they sent me to
Calcutta* b* No, even though I live in Calcutta, I went there this
time* c* Yes, even though I didn't go to Calcutta, I saw Bengal* d*
No, even though I lived in India, I always lived in cities* e* No, even
though I want a new car, I have never been able to buy one* 5*
Pattern: sentence a* V/hat things did you like in Calcutta? b* V/hat
people did you meet in Calcutta? c* V/hat places did you go in
India? d* \^hat cities have you visited in India? e* \/hat other
things did you see at the store? 6* Pattern: sentence 6* a* Nothing*
Buddenly it gol; very hot in Calcutta, and I wasn't able to rest* b. No
one* Suddenly it got very hot in Calcutta, and my travelling about
was hampered* c* Nowhere* Suddenly it got very hot in Hay, and
my travelling was stopped* d. ^ Hany* It gets very cool in Delhi,
and I always went there in winter* e* Hany things* But I had no
money, and I was not able to buy* 7* Pattern: sentence 7* a* Still,
did you see any places in the city? b* Still, did you meet any people
there? c* Still, did you go to many places in Bengal? d* But did you
go to the mountains in the summer? e* But did you not go to the
bank?
 299 8. Pattern: sentence 8. 9. a. b. c. d. e. Yes, I went
aroimd the Hugli one day by boat. Yes, I went around the city one
day by taxi and saw people* Yes, I went to Konarok in Orissa by
bullock-cart* Yes, I went to the mountains by train* Yes, I went to
the bank by tram this morning* Pattern: sentence 9» a* Did you see
the Kali temple in Kalighat? b* Did you meet any painters or writers?
c* Did you see the temple at Puri? d* Did you go to Dehra Dun? e*
Did you get some money there? 10* Pattern: sentence 10* a* Yes, I
had time to see that. b* Do, I did not have time to meet them* c*
No, I did not have time to go there. d* Yes, I went to Dehra Dun
and Mussoorie Cmusuril . e* No. The bank was closed, and I had no
time to wait* 11* Pattern: sentence 11. a* V/hat did you do on the
other days? b* liVhere did you go on the other days? c* V/hat did
you do for the remaining time? d. V/hat did you do in Dehra Dun? e*
V/here did you go after that? 12* Pattern: sentence 12* a* The
remaining days I sat on my veranda and slept* b* The remaining
days I sat in my chair and read* c* The remaining days I went and
looked at paintings, d* I rested and talked with people, e* I went
and looked in some book shops. 15* Pattern: sentence 13» a* How
many weeks were you in Calcutta? b. How many months were you in
Bengal? c* How long were you in India? d* How many years were
you in India before?
 300 e» How long were you in India before? f. How long
were you in the book shops? 14. Pattern: sentence 14» a- I was in
Calcutta only five weeks. b. I was in Bengal exactly two months and
three days. c. I was in India five months. d. I was in India almost
five years before. e. I was in the shops about two hours. 15.
Pattern; sentence !?• a. How did you like the trip? b. How did you
like Bengal? c. How did you like India? d. How did you like coming
home? e. How did you like the shops? 16. Pattern; sentence 18. a. I
liked the trip very well. b. I didn't like Calcutta at all* c. I liked the
country very well. d. I liked coming home. e. I didn't like the shops
very well. Lesson 16. part 4. Sentence Brills* Brill 1 —I did not see
you last month* Were you not in the city? — No ) I went to
Calcutta* — I thought perhaps you had gone there* Bid you see
your brother and sister there? — No, even though they live there, I
did not have time enough to see them* — Bid you. see many places
in the city? Uo, if only I get my vacation next month, I shall go back
and wander around the city* — Bid you like it, then? — Yes, I liked it
very much* But it got very hot in the city and I could not wander
around very much*
 501 — Were you able to see the Jain temple? — No» I had
heard about it» and I wanted to go* But I did not have the time. —
li'/hat did you do there, then? — When it was not too hot, I worked.
V/hen I could not work, I stayed in my room and read a book. —
How many days were you there? — I stayed there only three days*
Then I went on to Outtack. Brill 2 — Bid you go to a village for
Burga-puja? — Yes, I went to the house of a friend of mine in a
village near Bankura. — How did you like it? — Wonderful. The
people were very open-hearted and took good care of me, even
though I was a foreigner. — l(7hat did you do? — In the morning
and the evening we went to the temple. In the afternoon we often
went for a walk. — There is a Santal village nearby, isn't there? Bid
you see the Santals? — Yes, there is a village there in the jungle.
One night we went there to see a dance. — And did you hear any
Baul songs? — Yes, one afternoon a Baul came and sang for us.
Even though he was very old, he sang beautifully. — If only I could
collect those Baul songs, people would be able to hear their
sweetness. — Rabindranath did collect a few* They are beautiful.
Lesson 16, part 5* Vocabulary. bidesi foreigner soqgraho korcollect
madhurjo, mis’tota sweetness buyo , briddho old man bises special,
especially ador love. prankhola open-hearted affection pran heart sit
kal winter khola open, frank, candid porbot mountain npurbo
unprecedented. joqgol jungle very wonderful ebar, eibar this time
bondho hindered, stopped, closed
 502 sommondhe post-position, "in regard to", with genitive
Idioms: — ke odor jotno korhate besi somoe achsomoe patai na to
take good care of, to treat with great kindness to have enough time
is it not so? (note intonation)
 Lesson 17 » part 1« Oonversation Analysis and translation
Bengali !• stem of verb "remain" past habitual tense suffix 2nd
person ordinary past tense ending "(you) used to remain/ live" A.
V/here did you used to live? 2» past habitual tense suffix 1st person
past tense ending "(I) used to remain/ live" ® • I used to live in b
yambazar before* l\'ow I live in Jihowanipur* high stern of verb
/poy-/> "study" past habitual tense suffix 2nd person ordinary past
tense ending "(you) used to study" thak- 2TRH -e -r thakte 2TRTO
A. isrnr^r T:^JT2nn j2tr^ ? tumi age ' kothae thakte " -t-um
thaktum B. srrfti isnT|T »rrrq
 "university" A» Ji)id you used to study at Calcutta
University? "study for the B*A. " B. Yes, I studied for the B. "" B»A»
at Calcutta University* loan word, "university" A* At which college of
the A* University did you used to study? name of a college of
Calcutta University, "City College" name of a college of Calcutta
University, "Presidency College" B* Pirot I used to study at B* City
College, after that at Presidency College* A* Bid you used to go to
A* ~ see many football games in Calcutta? bissobiddaloe T<1^?1?i3
presidensi kolej ISlf?rCv53fl’ srrt^T SESfw fy\f^ ^ ^ OTmw WTO I
ami prothome ' siti kole.ie * tar Pore ' presidensi kole.ie ' portum
rmv5 IW5 ? tumi ki kolkatae * khub phuj?bol khsela * dekhte .jete "
 8 505 "often" emphatic suffix "very often" prae Stm -i -t
praei B. Yes, when friends went B. "^It , CTHTR TOT T^lt^ CTTpST
with me, I used to go "OTT I to watch the game very often* h^ "
bondhura * amar songe gele * ami praei * khasla dekhte .ietum " 9*
loan word, "coffee house"; there are several in Calcutta, very
popular with students and intellectuals "conversation, gossip" A. And
did you used to go A* to the coffee house to talk very often? 10.
"between" "from time to time" jB. V/hen I had no more study- B.
ing, I used to go there from time to time. 11. "vacation, day off" A.
VJhat did you used to do A. 2R vour days off? "" 12. "field", a large
common in the middle of a city like Calcutta kophi haus ‘5T3JT
golpogujob ^ VTU3 ? ar tumi ki praei ' golpogu.iob korte ' kophi
hause ' .jete " majhe majhe majhe VJ ^Tv?n?»rrTr snwr srTftr -
umrp^ I porasona na thakle ' ami ma.ihe ma.lhe ' sekhane netum "
chu’j^i chutir dingulote ' tumi ^ ki korte " moedan o
 B. Wien my sister used to B. XTPTjrWT WCo i5C^ , OTC^
come to see me» I used ISTI'^n:^ TTOJ V|U*i1 ‘Wv^l Cvo I to take
her for a walk on the maidan. amar bon » dsekha korte ele » take »
.amar songe nie » moedane basrate .1 etum " "heat, hot season"
grisso 5^^ A. What did you used to do A. SfhC’SRI 5«TBCvi) \5^
^5?TCo ? in the long summer vacation? grisser lomba chutite » tumi
ki korte " "body" "be in good health" hill station in North India sorir
sorir bhalo thak- v5T«T 2lT^ Simla fywrr B. When my mother and
father B. gWT?[ TfWf were in good health* we TWITCvS 'Wv^Uvi) I
used to go to visit Simla* amar ma-babar » sorir bhalo tha.kie»
simlate basrate .ietum " idiom: "didn't you?, isn't that so?" A* You
used to write poetry A* ^ in college, didn't you? “ noun, "journal", a
common name of journals compound verb, "be published, come out"
B* Yes, my poetry used to be published in the college loumal very
offem tai na TT i^wvs , ^ m ? tumi koleje ' kobita likhte ' tai n^-n
potrika bar ho- ^TKf TSrB. ■str , isrnrra •ms "rfimro “• gnnt :gr?i
tost i hffi " amar kobita ' kole.i potrikate ' praei bar hoto ~"
 507 17* A. You used to do other A. Cf'ra ffrf^ ? things in
college ^ didn’t you? tumi kole.ie » ar kiohu korte » naki " 18* B.
Yest I used to nlay tennis B when I got a little time» and I us-ed to
play cricket often» 19* "job" "games" compound verb stem, "give
up, leave" B. But now I have a .iob» That is why I have given UP
games. Lesson 17, part ■^tr , cnirr ,srra gm:j ym i hge " ami ektu
somoe nele * tenis kheltum * ar prae somoe * kriket kheltum " cakri
M which is affixed to the verb stem. To the tense sign /-t-/ are then
added the past tense personal endings. ken- "buy" ami kin - t - urn
tumi kin ~ t - e tui kin - t - is apni kin - t - en se kin - t - o tini kin - t
- en
 khsel"play" ami khel - t - urn, etc kor"do" ami kor - t - urn,
etc. son"hear" ami sun - t - um, etc. jan"know" ami jan - t - um, etc.
b8eya"wander about " ami baeya - t - um, etc de" give " ami di - t -
um, etc. ho"be" ami ho - t - um, etc. kha"eat" ami khe - t - um, etc.
The verb stem /ja-/ is regular, having the stem /je-/ in the past
habitual. 1.3. This tense and the simple past are the only tenses
which permit the formation of the negative with /na/ : I used to play
kheltum I did not used to play kheltum na 2. As in sentence 4, the
Bengali usage is to make /bi.e/ the direct object of /poy-/» "study
(or "read") B.A. ", where English usage will be "study for the B.A."
Lesson 17, nart 3» Patterns. 1. Pattern; sentence !• a. Where did
you used to go? b* Where did she used to live? c. Where did they
used to meet you? d. Where did you (pl«) used to study? e. Where
did he used to live? 2« Pattern; sentence 2. a* I used to go often to
Kalighat (/kalighaj?/) before. b. She used to live in Ballygunge
before. c. They used to come to my house, a long time ago. d. We
used to study in that room. e. He used to live in Calcutta.
 Pattern: sentence 5. a. What part of Kalighat did you used
to go to see? In what part of Ballygunge did she used to live? c. In
what part of the city did they used to live? d* In what field of study
did you (pi*) used to work? e. In what part of the city did he used to
live? Pattern; sentence 6a* a* I used to go to see the Kali temple*
"b* She used to live near lariahat (/goyiaha’J;/)* c* They used to
live in Oitpur Road (/citpur ro(^[/)* d* We used to study Bengali
literature* e* He used to live near the river* Pattem; sentence 6h*
a* After that I used to walk along the river* B* After that she used
to live near the lake* c* After living there for ten years > they went
to Poona* d* After that we Began to study Sanskrit (/^oqskrit/). e*
After that he used to live with me most of the time* Pattern;
sentence 7* a* Bid you used to see many Boats on the river? B* Did
she used to Be aBle to see the lake from her home? c* Did they
used to Be aBle to come Back to Calcutta? d* Did you used to Be
aBle to read Sanskrit well? e* Did you (pi*) used to meet Sipra
often? Pattern; sentence 8* a* Yes, when my friends went with me,
we used to go in a Boat to Shalimar* B. c* d* 6 • Yes, when she
lived in that house, very clearly (/spos-jfo/)* she used to see the
lake No, when they went there, they didn’t used to come* Back
often* Yes, when we were studying, we used to read very well* Yes,
when my friend went with me, I used to go to her house
 ppitnnMifii mwmmi 510 7» Pattern: sentence 9. a. Did you
(pi.) used to go in the boat often? b. Did she used to go to the lake
often? c. Did you used to see them very often? d. Did you (pi.) used
to read kavva (/kabbo/)? e. Did you used to meet her parents often?
8. Pattern: sentence 10. 10. a. b. c. d. e. vVhen I had no more
studying* we used to go from time to time. \/hen she had no more
studying* she used to walk there. ViHien we had the time* we used
to go to see them. When we had learned enough* we used to read
kavva. v/hen we went there* her parents always used to be there.
Pattern: sentence 11. a. b. c. d. e. What did you used to do on the
trip? v/here did she used to walk there? Where did you used to stay
in Poona? Where did you (pi.) used to study Sanskrit? \/hat did her
father used to do? Pattern: sentence 12. a. \/hen we used to go on
the river* we used to read and sleep all the time. ^ ^®®^ there,
she used to walk along the lake c. d. ./hen we used to go to Poona*
we used to stay with my sister. When we studied Sanskrit* we used
to study with a pandit (/pon^it/ — see vocabulary). '' v/hen we
knew him* her father used to write poetry, lesson 17* part 4.
Sentence Drills. Drill 1 “-Have you been to Calcutta? "lt®Caioutla
toiveJeUy. ^ At what college of the University did you used to study?
I studied for the B.A. at Presidency Uollege. ii'hen 1 studied for the
11. A. at bt. Xavier’s College. — Did you like the city?
 bortoman (somoe) nouko lek, dighi bhromon ser present
(time) boat lake trip seer (about two pounds weight) bas korgolpo
bolgolpo kormone rakhlive (make dwelling) tell a storygossip
remember purono din olden times spos-^o, posi^o sosta koek
ponero clear, clearly cheap a few, several fifteen Sob somoe praei all
the time, incessantly usually, very often pon(3liter kache baeyate
(gie) Esk ser cal with a pandit (scholar) (going) on the trip a seer of
rice
 Lesson 18 > part 1» Oonversation Analysis and translation
Bengali high stem of verb /po?-/» "read" past tense suffix 2nd
person ordinary past tense ending past continuative, "you were
reading" A. John> what hook were A* you reading? " noun» "novel"
high stem of verb / dsekh-/» "see" past tense suffix 1st person past
tense ending past continuative, "I was looking at" B. I was looking at
a B. Bengali novel* “ interrogative pronoun stem, "who" "whose, of
whom" verb stem, "write" po];’-chil- — 1^-“ -e -X poychile ^ ? .iou *
tumi * ki boi porchile " uponnas @i i ^i 33kta ' banla uponnas '
Aekhchilum " ka- ^ kar
 verlDal noun/adj ective "writing, written" "written iDy
whom" lekha kar lekha "C^TT A. Who wrote the novel you ” were
looking at? A. ^T?r ? kar lekha unonnas * dekhchile " name of a
19th century Bengali novelist name of a Bengali novel B. It was
Anandamath, writ-. ” ten hv your Bankim-hahu* "is it not so?" A»
You read Bengali hooks, don't you? a stem of irregular verb "go"
(/ja-/) an adjectival suffix "gone, past" high stem of verb, "learn" B.
Yes, in the nast two years B. I have Been learning a little Bengali*
1st person present of stem /daekh-/ , "see"; "I see" or "let me see"
question marker negative "whether or not" hoiQkim anondomo^h d i
■(.vDivii ra i tomader honkim hahur lekha ' anondomoth " naki tumi '
hanla hoi poro J^aki " go-to goto 510 sikh•sTt , -510 ^ o WT 1 hae
" ami » goto du hochor * ektu hanla hhasa ' Sikhchilum " dekhi ki na
TT kina
 315 Bo So I thought) "Let me see B "" whether or not I can
read the writing of Banlciin-hahuo " 7. untranslatable particle which
transmits a feeling of condition or doubt on the part of the speaker
"strike, or seem or be difficult (for)" A. I think that his writing A. “
will be a little difficult for you# 80 - Bo V/hy do you say that? Bo
 316 11. adjective, ’’current" name for colloquial Bengali
language adjective, "pure" name for literary Bengali language "or"
A» \fiien you were learning " Bengali, were you learning the
colloquial of the literary language? 12* "two, hoth" emphatic suffix
B. I was learning both the "" colloquial and the literary language.
13« A. Look, if you leam a "" little Sanskrit it will he very expedient
for you» 14* noun, "India" stem of. verb, "go" ast tense suffix with
vowel-stem verbs) lat person past suffix "I was going" "another"
ijective, " cultivated" "person" "gentleman" colit colit bhasa ofsivo
oWT sadhu sadhu bhasa na, ba TT , ^ A. 0;^ OTT oW ©2K ©wr TT
TTI^ Qw ? tumi .iokhon ' banla bhasa sikhchile * tnkhon ' tumi ki ’
oolit bhasa sikhchile » na §adhu bhasa sikhchile " dui ^ -i B. mm ^
pPif^^ i ami ’ oolit o sadhu bhasa * duii sikhchilum " A. vn , v5;;;i^
^ r-w m “ TT^snrRi ^ i daskho * tumi jodi * ektu sonskrito sekho *
ta hole tomar * boro §ubidhe hobe ’’ bharot, bharotborlo ST?F5 ,
oT?R55l^ ja- JTT-oohil-urn j’acchilum ar sek {5fT?I bhoddro . ^ 3,uk
WT^ bhoddrolok SBEill«TTR* $ \
 ta ^ ta.i " that'* "that (emphatic)" 1* When I was going to
India last year< another Bengali gentleman told me the Sfljne thi-
np;. 15* A. Why were you going to India last year? 16* "speech*
address" B. lo give speeches in your country. 17* post-position,
"conceding" (preceding genitive optional) A* To give speeches about
America? 18* stem of verb, "read" causative stem of verb "read"
(i.e., "teach") past suffix ( with vowel stems ) 1st person past suffix
"I was teaching" "connection, relation" post-position "in regard to,
about" (preceding genitive optional) B. 5IS ^ crrfsT WT ^ era
05X^1
 518 B. Yes. I was teaching B. ( ab ou t j Am e r i literature.
19. "wish, desire" "government" B. 'lhat is why the govern- B.
ment*s wish was that I give a speech about that. 2C. "whereabouts,
in which different places" A. In which different places A. “ in India
were you giving speeches? 21. "the greatest, the most" "of the
greatest" "part, portion" "the majority, the greatest part" B. Ihe
.;reatest part of the B. “ time I was giving speeches in Calcutta itself.
22. A. How did you like Bengal? A. 23* "extremely" "special,
particular" function wordj see Grammar , 3 • %T , crrirr I hS " ami *
amerikan sahitto sommondhe * poracchilum " icche tew sorkar tai *
sorkarer icche chilo * ami oi bisoe ' boktrita dii " kothae kotliae
WmTI wmn x^rm ^ tumi bharot borse * kothae kothae ’ boktrita
dicchile " besi bosir bhag 0T5T be sir bhag 3Trf^ TO? vi)l (.0^ I flTnj
* besir bhag somoe * kolkatatei * boktrita dicchilum " OT 'm
^rr^rT^x^rr ? ta ‘faoMar * banla des * kganon lagchilo " bhari
STXll' bises "f^X^ kore
 519 "especially" B. I think that Bengal is an B. extremely
beautiful place » esTPecially Calcutta city» 24» "mouth" A. I like very
much to hear A* this (v/ordj from you~r mouth* biles kore T<1
1*^15 srnrra wr or# OT151T I *r^ i amar mone hoe .ie * baqla del
* bhari sundor .iaega ' bises kore ' kolkata sohor " mukh vov^ ^
V2Tu^ d wr srnTT?r o l ^T «TT^l (.^ I tomar mukh theke * e kotha
lune * amar bhari bhalo lagche " Lesson 18 > part 2« Grammar* 1.
(Che formation and use of the past continuative* 1.1. (Che use of
the past continuative (sometimes termed past imperfect) is to
indicate that an action had begun in the past and was continuing at
the past time referred to by the speaker. A rule of thumb is that
wherever the fom "was/v/ere ...ing" is used in English, the past
continuative is used in Bengali. (Thus; lunchilum dekhchile khelchilo
"I was listening" "you were looking" "he was playing", etc. 1.2. fhe
tense is formed by the addition of the past tense suffix and past
personal endings to the high stem of the verb, except where the
stem-vowel is /a/ or the shape of the stem is OVOa-. vi/liere the
stemvowel is /a/ and where the shape of the stem is CVCa-, the low
stem is retained. (Chus; Ion- "hear" ami lun-chil-um tumi lun-chil-e
tui lun-chil-i apni lun-chil-en le lun-chil-o
 tini sun-chil-en pheel- "drop" ami phel-chil-um, etc. bos-
"sit" ami bos-chil-um» etc. /a/-stems retain their low forms; jan-
"know" as do OVOa-s terns; jana- "cause to know" sona- "cause to
hear" jan-chil-um» etc. jana-chil-um, etc. sona-chil-um, etc. 1»3*
CV-stems follow this same pattena; all stems are high except where
the stem-vowel is /a/. CY-stems, however, also double the /-c-/ of
the /-chil-/ suffix; ne- "take" ami ni-cchil-um, etc. ho- "become" ami
ho-cchil-um, etc. ja- "go" ami ja-cchil-um, etc. 2. formation of verbal
adjectives, as in sentence 3. 2»1* Verbal adjectives may be identical
in form with verbal nouns; only their syntactical function separates
the two classes. Some examples of verbal adjectives; e'amar hate
lekha boi" akas kalo kora dhoa" o*j?a'kharap lekha boi" e“^a'bhalo
aka chobi" this is my hand-written book (this book is written by my
hand (i.e., in my handwriting)) the smoke making the sky black (i.e.,
the sky-black-making smoke; /akas kalo kora/ is an adjectival
complex modifying /dhoa/. ) that is a badly written book (extremely
colloquial) that is a well painted picture (extremely colloquial) 2. 2. It
should be mentioned that there is another type of verbal adjective,
which functions somewhat differently syntactically. This
 second type of formation is much less frequent (except in
certain stylized idioms) than the one above* Note the sadhu—bhasa
vocabulary in the following examples: e boi ' amar hosto likhito” this
book is written by my hand o boi'j;;a*mondobhabe likhito” that book
is badly written 2* 2*1* 'fhis form is called in traditional grammars
"past .passive participle"; it should be noted that the construction
/akas kalo kora dhoa/ cannot be transformed in this way; "past
passive participles" form a limited class in modern spoken Bengali*
3* Function word /kore/ » as in sentence 23* 3*1‘ It should be
noted that in this situation, as in that mentioned in lesson 16, the
foimi /kore/, while it has the same form as the PAP of the stem
/kor-/» "do", does not act in the same way* A PAP has a verbal
function in a sentence: se kaj kore'gselo" He did the work and went*
se bayite phire'boslo" He returned home and sat down* The function
word /kore/ occurs either in immediate relation as a noun: Se nouko
kore 'ale" He comes by boat* or, as in the present case, as an
adjective: se biles kore ' sohor-j?a' He especially likes the city*
pochondo kore" se sokto kore'dhore" He holds it firmly* Lesson 18,
part 3* Patterns* 1* Pattern: sentence 1. a* V/hat picture were you
looking at? b* v/hat song were you listening to? 0* V/hat stories
were you reading? d* V/hat songs were they singing? e* Vfnat
novels was he reading?
 522 2» Pattern: sentence 2* a. I was looking at a picture
iDy a jiengali painter* Id. I was listening to a song iDy a Bengali
writer, c. I was reading some Bengali short stories* d* Phey were
singing some Bengali songs, e. He was reading some Bengali
novels* 5* Pattern: sentence 5* a* Jho painted the picture you were
looking at? h. \Vho wrote the song you were listening to? c. i/ho
wrote the stories you were reading? d* V/ho ^^rrote the songs they
were singing? e. \/ho wrote the novels he was reading? 4* Pattern:
sentence 4* a* It was a picture painted hy Jamini Roy. h. It was a
song written hy Rabindranath* c. Tney were stories written hy
different people, d* 'Ihey were songs written hy kaviwallas
(/kohioala/) * e* They were novels hy Baratcandra (/sorotcondro/) »
5* Pattern: sentence 5* a* You like Bengali pictures, don't you? h*
You like Rabindranath's songs, don't you? c. You have studied
Bengali a lot, haven't you? d. You listen to all kinds of folk songs,
don't you? * e* You can read that kind of Bengali, can't you? 6*
Pattern: sentence 6* a. Yes, for the past ten years I have been
studying Indian painting. h. Yes, for the past few years I have been
listening to many Indian songs. c. Yes, for the past six years I have
been studying Bengali. d. Yes, for the past twenty years I have been
listening to folk songs. e. Yes, for the past several months I have
been learning to read ladhu-bhasa* Pattern: sentence 6.
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