Emergency surgery, for the general practitioner

Front matter

Class. 3\i \t?^ Book q )G B j

EMERGENCY SURGERY

SLUSS

Dedication

TO MY PRECEPTOR, DR. E. B. EVANS, TYPE AND EX- EMPLAR OF GENERAL PRACTITIONERS, IN MEMORY OF DAYS SPENT TOGETHER, THIS LITTLE WORK IS INSCRIBED

[USHARY of C0NGRESS5

I, III igrtw iiiwmiiir'^'^

Preface

This is a Surgery for the general practitioner: written not to instruct his leisure hour, but in the hope sometime to serve as a guide oi^t of uncertainty in a time of stress. Its merits and demerits should be reckoned from that point of view alone. If, occasionally, the form of expression seems dogmatic, it merely comports with the constant aim to be practical; certainly that aim has denied any place to theoretical discussions and has curtailed reference to the various views of recognized authority. An absence of bibliography, it is hoped, therefore, will not be regarded as discourtesy to the many writers, teachers and practitioners whose ideas have been so freely appropriated.

Among the text-books more constantly consulted are Senn's Practical Surgery, The American Text-book of Surgery, Walsham's Surgery, Treves' Operative Surgery, Lejars' Chirurgie d'Urgence, Veau's Chirurgie d'Urgence et Pratique Courante, Von Bergmann's Chirurgie and Binnie's Operative Surgery.

The Annals of Surgery, the American Journal of Surgery, the International Journal of Surgery and the Journal of the American Medical Association have been prolific sources of information.

For advice and aid in many ways in the preparation of this book, special thanks are due Drs. John J, Kyle, James H. Ford, A. W. Brayton and Gustav Bergener. The original illustrations are the work of Dr. Helen Knabe.

To the publishers, through whose counsel and patient criticism the book has grown into its present form, a grateful appreciation is to be expressed.

Vll

Chapter I

The General Practitioner as an Emergency Surgeon: His Duties AND Responsibility: Equipment i

CHAPTER n.

Emergency Antisepsis. Operation in a Private House 6

CHAPTER HI.

Anesthesia to

CHAPTER IV.

Sutures; Methods and Materials 19

CHAPTER V.

Drainage 25

CHAPTER VI.

Dressings, Bandages, Splints 28

CHAPTER VII.

Shock 42

CHAPTER VIII.

Hemorrhage 46

CHAPTER IX.

Wounds: General Principles ^ 59

CHAPTER X.

Wounds op Special Regions '69

f CHAPTER XI.

CHAPTER XII.

Gunshot Wounds in Civil Practice 142

CHAPTER XIII.

Fractures 151

CHAPTER XIV.

Injuries to Joints 220

CHAPTER XV.

ix

X CONTENTS.

CHAPTER XVI.

Injury and Repair of Nerves 260

CHAPTER XVII.

Abscess 278

CHAPTER XVIII.

Phlegmon: Acute Spreading Infections 322

CHAPTER XIX.

Acute Osteomyelitis » sss

CHAPTER XX.

Septic Arthritis 340

CHAPTER XXI.

Foreign Bodies 350

CHAPTER XXII.

Burns, Scalds and Frost-bite 366

CHAPTER XX. Suture and Ligation of Arteries 584

CLIAPTER XXI.

Practical Amputations 595

CHAPTER XXIL' Dilation of the Sphincter Ani; Operation for Piles; Operation for Anal Fistula 649

CHAPTER XXIII.

Phimosis; Paraphimosis; Circumcision; Hydrocele; Castration 656

CHAPTER XXIV.

Ingrowing Toe-nails 667

CHAPTER XXV.

Removal of Small Tumors 670

CHAPTER XXVI.

Skin Grafting 673

EMERGENCY SURGERY.

Chapter I. The General Practitioner As An Emergency

SURGEON: HIS DUTIES AND RESPONSIBILITY.

EQUIPMENT.

Surgery is no longer reserved to the elect few. That its beneficence shall be denied a place in every practitioner's art is repugnant to the spirit of the times. Modern life is complex: every profession and every calling has its specific duty to perform. Whether the medical profession shall continue to play nobly its large part in the social drama depends upon the general practitioner. The hope of the profession rests in him. But there is a price to pay the age for high respect. That price to the medical profession is nothing less than the fulfillment of its therapeutic promise and the realization of its surgical opportunity. The opportunity is golden; for with the wonderful improvements in surgical technique, the field of emergency surgery, that is to say, the indication for immediate intervention, has been remarkably broadened and the time finds the public singularly favorable to that form of relief.

The "horror of the knife," of all that pertains to surgery, has become a tradition, like the practice which gave it birth. Indeed the public is trained to expect that in the face of grave emergencies, the practitioner will do something effective; however serious the required intervention may be, if it but offers hope, the doctor is expected to act. Our predecessors — even those able and willing — often found their hands tied under such circumstances by the ruling policy of "let alone and let die." It is a part of their glory that they conceived,

2 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON.

planned, and attempted in the face of tremendous obstacles, most of the interventions of urgency which are current today.

The surgical opportunity, then, of the general practitioner is clear, and his duty as well. The professional spirit, the humanities, his conscience, make it incumbent upon him to know and act. This he must do or drop to the rear in the march of progress, which does not halt for the timid or unwilling.

But the task imposed is heavy, the responsibility large; for the general practitioner often finds himself isolated, remote from special counsel, perhaps compelled to act alone. That he does not always rise to the surgical emergency and do all that he might do even under unfavorable circumstances, may often be laid in large part at the door of his training. He knows often what he ought to do, yet knows not how to do it. Happily the courses of instruction are now generally planned to do away with this strange antithesis between theory and practice: a theory, modern, scientific, positive; a practice, as Lejars says, still often full of error and based on empiricism age-old.

But this must not be; for now that the indications for operation are exactly defined and one's duty obvious, vague conception of an operation as something far away and desperate, must give way to clear notions of the resources of surgery, of surgical therapeusis. Every doctor must familiarize himself wdth the technique of interventions which he must undertake at times, if he is not to be inexcusably remiss in an almost sacred duty.

Surgery in one respect is a handicraft, and as such requires its certain tools of first necessity. If, as has been said, emergency surgery always comes in the nature of a surprise, then the surprise will at least be less complete if one has an equipment and has it prepared.

Every doctor should have an emergency bag supplied with materials: hand brushes, soap, a fountain syringe, hypodermic syringe, catheters, flasks of alcohol, ether, chloroform and carbolic acid, bichloride tablets, a package of sterile compresses, sutures, bandages, a box of Plaster-of-Paris and certain instruments.

Hand Brushes. — These are almost indispensable for emergency sur-

EQUIPMENT, 3

gery. They should be kept wrapped in the case and sterilized before using. If necessary one may scrub the hands and field of operation with sterile gauze.

Fountain Syringe or Irrigator. — One may use the full rubber outfit or, w^hat is better, a porcelain container and a long rubber tube with glass nozzles. It is absolutely essential that the whole be sterilized by boiling. It is nonsense to sterilize, as is often done, the canuloe and container and neglect the tube. The glass nozzles are likely to be broken if plunged directly into boiling water or if cooled too rapidly. If the porcelain container is used it may be boiled and then singed with burning alcohol. It takes up but little room in the bag, and the tube and nozzles may be wrapped up and packed in it and the whole wrapped and kept clean and dry. This outfit is almost indispensable, for in many emergencies the only adequate treatment is by hypodermoclysis or intravenous infusion.

The Antiseptics. — The alcohol must be kept in a well stopped flask and the carbolic acid or lysol, also. The bichloride may be in the form of tablets, so that the strength of a solution may be readily calculated. The most commonly employed is the formula containing, mercury bichloride 7.3 gr., citric acid T)-^ gr. This tablet in one quart of water makes a 1 to 2000 solution, which is as strong as need be used. One to three pints makes a i to 3000 solution and so on. Instead of the tablets one may keep a concentrated solution of bichloride in alcohol.

Bichloride of Mercury, 5 j-

Alcohol, § j.

One teaspoonful to a quart of water makes a i to 2000 solution;

One teaspoonful to 3 pints, i to 3000, etc.

Anesthetics. — One should keep on hand at least one pint of ether and four to six ounces of chloroform. Cocaine for local anesthesia is best kept in tablet form and the solutions made extemporaneously.

Sterile Gauze. — Too frequently the practitioner commits the error of depending upon absorbent cotton for his sponges and compresses. Absorbent cotton, as found on the market, is scarcely ever aseptic. Even if it is, it is almost certain to be contaminated in getting it out of the package. A supply of sterile gauze is one of the best means of

4 THE GENERAL PRACTITIONER AS AN EMERGENCY SURGEON.

promoting an aseptic operation. It should be kept in a hermetically sealed package of metal or glass.

In lieu of the gauze compresses ready sterilized, one may carry a supply of ordinary gauze which can be cut into appropriate sizes, and sterilized at the time of operation. It is a good idea to cut two sizes; a small for compresses and wipers, a larger to cover the field of operation. All these pieces should be folded once and the borders hemmed. A ball of cotton may be hemmed in between the layers, which makes a still better sponge.

Sutures and Ligatures. — If these materials are not already sterilized and in a special package, catgut must be ruled out, for its preparation takes too much time. One should take care to have several sizes of silk, especially the O and OO, for these are the sizes required in intestinal work.

Catheters and bougies should be kept in a metallic box. Rubber and metal catheters are always readily sterilized by boiling.

Drainage Tubes. — These should be preserved in a box or bottle which may be boiled thoroughly before opening.

Plaster should be kept in a tin box with tight cover and may be loose or already rolled. A supply of roller bandages is, of course, always kept on hand from which the plaster bandages may be made.

Instruments. — Any list which might be enumerated must, of course, be subject to the widest variation. But the feeling of greatest confidence goes w^ith the consciousness of having the necessary things with which to act. On the whole, the doctor should pride himself upon the completeness of his outfit rather than upon his ability to improvise. One should have as the minimum: scalpels, two sizes of amputating knives, scissors, grooved director, dissecting forceps, artery forceps — the more the better — two retractors, a saw, a bone chisel, needle holder and needles, tracheotomy tubes, and an Esmarch tube. The instruments most frequently used may be put together in a small metal case, while the others may be kept in larger cases or wrapped, or rolled up in a bundle.

Cleaning instruments and preserving them from rust is a matter of no small importance. After each operation they should be taken apart, scrubbed with soap and warm water, wiped with gauze satu-

CLEANSING INSTRUMENTS. 5

rated with alcohol, and dried thoroughly. "If the cleansing has been delayed, it may be necessary to immerse them for a short time in a solution of potash and finally cleanse in the manner described. If any stains still persist they should be polished with chamois skin. Too often the practitioner neglects his instruments because, perhaps, not often used, and in the emergency he finds himself with knives rusty and without an edge, scissors that will not cut, and forceps that have no grip. He will certainly gain time by spending a little time in carrying out these small details.

L

Chapter II

EMERGENCY ANTISEPSIS. OPERATION IN A PRIVATE

HOUSE.

The preparation for an urgent intervention outside of an operating room resolves itself into a question of asepsis or antisepsis, and around this point gathers a multitude of details. But it is necessary only to proceed systematically and intelligently to achieve excellent results.

The time was when the idea prevailed that an aseptic operation was scarcely possible outside a hospital. This was a harmful notion which restrained many a practitioner from an effort that might have saved his patient's life. Every day it is demonstrated that aseptic work is not peculiar to formal operating rooms.

Bonney, of Philadelphia, writes that he has done many major operations in the homes of the poor in the midst of the most unsurgical surroundings; nevertheless, the results have been excellent. Most of these operations were for urgent abdominal, pelvic, or genito-urinary disease, and though such w^ork is often time-consuming and laborious, yet it shows what can be done in the case of necessity. Bonney attributes his success with inflammatory conditions to complete removal of diseased tissue and free drainage in pus cases.

Van der Walker (Month Cyclopedia of Pract. Med., Aug., [906) says that for thirty years he has operated in farm houses throughout central New York with as good results as those obtained in the hospital with which he was connected for many years. He goes further and concludes that for many reasons, it is desirable that there should be a return to more home operating, and that the hospital ought to go back to the original purpose, the care of the homeless and sick poor, and not invade the home with the arrogant assurance that only within its walls can the surgical case be cared for.

But this is aside from the main point: the practitioner may jeel

PREPARATION OF THE ROOM. 7

assured that with decision, knowledge and system, even under apparently imjavorahle circumstances, he can nearly always realize an effective asepsis.

As Lejars says, everywhere one finds water, fire, and linen; add salt and usually carbonate of soda: with these one may accomplish a sufficient sterilization of the instruments, the hands, the field of operation and the dressing. But it requires a will to do all the work, to proceed with method and, above all, quickly, through the minutia} of preparation. One should have a plan in mind and Lejars offers a model which, of course, can be modified to suit the circumstances and the operation. Suppose a major emergency, with every detail of the preparation to be supervised:

First Step. — Have a fire started. Have the available receptacles assembled. Review the stock of linens if you do not have gauze or muslin. Freshly laundered handkerchiefs and napkins (without fringe) furnish material for excellent compresses and coverings for the field of operation. Secure one or two large kettles — a copper wash-boiler — for boiling the water for the operation. Secure three smaller receptacles such as enameled stewing-pans; one for boiling the instruments and sutures, another for the brushes, irrigator, nozzles and tube, etc; the third, for the compresses and tampons. If possible boil also the dishes or basins selected to hold the instruments and the solutions needed during the operation. It is best to have a dish or bowl for the instruments, one for the tampons and compresses, one for the sutures, and two hand basins for sterile water and bichloride solution. The boiling must be prolonged at least a half hour to be sure of sterilization. It is a good plan to add a teaspoonful of salt to the quart of water containing the compresses which are to be tied up in a towel to facilitate their removal; and to add a teaspoonful of washing soda to the water in which the instruments are to boil. The instruments ought not to be put in until the water is boiling, as otherwise they are likely to be tarnished. When once the sterilization is under way proceed to the operating room.

SecondStep. Prepare the Operating Room and Table. — If there is any choice select the best lighted and largest room. If it is at night arrange for the illumination. Do not displace the furniture except to make

8 EMERGENCY ANTISEPSIS.

room for the operating table, two small tables, and room to "turn about." An extensive "clearing for action" does more harm than good, for by jerking down the curtains, rolling the furniture around and sweeping, one stirs up the dust, accumulating perhaps for months.

It is preferable simply to sprinkle the floor or wipe with a wet cloth. To be sure if one has several hours in which to prepare, then the room may be emptied, the floor covered wath moist sheets and the walls sprayed, as Quenu suggests, with peroxide; the tables placed and the room closed until the time of operating.

It is never a good idea to use the patient's bed for an operating table. The dining table can usually be pressed into service, covered with a blanket and that with an oilcloth. A table may be improvised from two wooden trestles with planks laid across and covered like the table. Of the two small tables required, the one on the assistant's side will hold the compresses, sutures, etc.; the other on the operator's side will hold the instruments.

Now give the patient the preliminary preparation. Shave the parts, if necessary, and if the operation is likely to be prolonged, wrap the lower limbs in blankets.

Third Step. — Everything having boiled sufficiently, carry the vessels into the operating room and empty the contents of each into its special receptacle.

If these bowls have not been boiled now is the time to sterilize them by singeing with burning alcohol. Into each pour two or three spoonfuls of alcohol and set it on fire, in the meantime tilting the dish in various directions so that the flame is brought in contact with the whole inner surface. W hen this is done, lift the compresses and instruments out of their boilers, place them in these sterile dishes and cover them with an antiseptic solution. This protects them from possible contamination until the operation begins. Do not open the bag of compresses till needed. Remember to use only a sterile dipper if necessary to dip out the sterile water in preparing the various solutions.

Fourth Step. — Direct the assistant to begin the anesthesia, and now prepare your hands. As Lejars remarks, this is a "science and art," the first duty of the surgeon. They are not to be prepared by a desul-

PREPARATION OF THE HANDS AND FIELD OF OPERATION. 9

tory rinsing in soapy water, or parboiling with a hot antiseptic solution, but by a patient and systematic scrubbing. Get your sleeves rolled up and pinned. Have before you two wash basins, one with hot and the other with cold sterile water. Pare the nails. Begin with soap and hot water. Lather the arms up to the elbow, and rub the soap in until the skin seems saturated and soft. Then begin with the brush; scrub the palms, the dorsum of the hand, between the fingers, all about the nails. One need not rub the skin off, to be sure, but continue the scrubbing for at least ten minutes, having the water changed several times; next rinse in the cold sterile water and then rub vigorously with alcohol to remove all the oils in the skin; finally soak in bichloride solution.

Fifth Step. — In the meantime the anesthesia has progressed. Prepare the field oj operation, by scrubbing with soap and water, followed by alcohol or ether and bichloride solution.

The disinfection of the skin must be, in every respect, as thorough and vigorous as that of the hands, and must extend well beyond the proposed line of incision in all directions, for one can never tell where the incision may finally end.

Again wash your hands. An untrained assistant changing the bowls may spoil the sterilization by getting his fingers or thumbs inside. Direct him how to lift and carry a bowl with his palms against the outside.

Having .completed the final cleansing of the hands, cover the field of operation on the four sides wdth four sterile towels or large compresses and fasten them with sterile safety pins or artery forceps.

Time gained by relaxing in the least any of these precautions of asepsis and antisepsis, is irretrievably lost; it is the operation, now begun, which must progress rapidly.

Chapter III. Anesthesia

Anesthesia is necessary in most emergency operations, not only to obviate pain, but because it is often essential to a good operation. Unfortunately, on the other hand, it adds to the doctor's task and presents some special difficulties.

In certain grave conditions, as intestinal occlusion, strangulated hernia, or abdominal traumatism, it may be the actual cause of death, however carefully administered.

Not only in emergency work, but in any case, general anesthesia should be cautiously induced and narrowly watched, and for this reason it is especially embarrassing to the doctor compelled to entrust it to the untrained in cases of urgency.

Chloroform has the advantage that it requires no special apparatus for its administration; and the smaller bulk is an item of importance, especially in military practice; moreover, it is much more pleasant to the patient. Unfortunately, it is many times more dangerous than ether, even in the hands of the skilled.

In lieu of a special inhaler, such as Esmarch's, fold a handkerchief, napkin, or compress several times to- form a square. Begin by pouring on several drops and gently approaching it to the mouth and nose of the patient. The inhaler should be managed with the left hand, leaving the right hand free to raise the eye-lid, or feel the pulse, or handle the container. Do not hold it too close to begin with, but give the patient plenty of air; in other words, give the chloroform wxll diluted. Give the patient time to get accustomed to the odor. Advise him to breathe through the mouth and distract his attention as much as possible; get his confidence, flatter him, and, in the meantime, study him and test him. The few minutes spent in this way will soon be regained.

Pour on five or six drops of chloroform at a time, and as the respiration becomes deeper hold the inhaler closer, giving the chloroform less

lO

CHLOROFORM ANESTHESIA. II

diluted with air. Replenish the supply every half minute, sprinkling it on the under side of the compress and quickly inverting it over the face.

As the stage of excitement comes on, push it more. When the anesthesia is complete, reduce the dosage but increase the frequency of renewal.

The drop method is ideal after the anesthesia has been attained. Small doses frequently applied mean the smallest total amount, which must be the anesthetist's constant aim.

The good anesthetist is not the one who can use the largest amount of chloroform without death, but the one who can hold the patient merely unconscious and relaxed with the smallest amount possible.

If the patient coughs or shows signs of nausea, increase the dosage at once. Do not begin the preparation of the field or any part of the operation until the anesthesia is complete.

Keep the pulse, the pupil, the face and the thorax under constant surveillance, for in this way alone may one determine the prognosis, good or bad, of the anesthesia.

The anesthesia is usually described as occurring in three stages: the first, stage of excitement; the second, loss of consciousness; the third, loss of reflexes or stage of surgical anesthesia. There is a fourth, stage of paralysis of the automatic centers, but this is a stage which the good anesthetist will never reach.

The excitement of the initial stage, in which the patient struggles or talks at random, is followed by loss of consciousness, but the reflexes are active, the pulse is full and bounding, the pupils respond to light, the eye-lid resents the corneal touch, the skin is sensitive, the face is flushed and the breathing deep and regular.

Beware at this time of sudden blanching of the face, of dilated pupils, of weakened pulse or disturbed breathing. If these symptoms arise, withdraw the anesthetic and prepare for artificial respiration. The patient is not ready for the operation and yet he may die in this stage.

Often pallor and dilated pupils precede vomiting, but when the jnilse and respiration are good, the nausea is to be quieted by more chloroform.

When the reflexes are finally abolished, the pulse should be full,

12 ANESTHESIA.

though perhaps a little slowed, the respiration quiet. and regular, the pupils slightly contracted and the face moderately pale. Any marked deviation from this standard during the operation is a matter for concern.

Weak heart action, uncertain respiration, dilated pupils, deep pallor or cyanosis, mean approaching paralysis of the automatic centers governing the circulation and respiration, and the anesthetic must be withdrawn until the symptoms improve under measures employed to stimulate.

In the case of the average adult, one and one-half to two ounces should be sufficient for the first hour and much less subsequently. Children and the debilitated require less.

Ether has the disadvantages in emergency work that it is dangerous to use near a light or fire and that its administration is a little more complicated, but beyond that, its anesthesia is never attended by sudden death in the early stages as is that of chloroform. It is followed by less shock after abdominal operations or other prolonged intervention. Bronchial affections are its chief counterindications. An inhaler may be fashioned out of a newspaper rolled into a cone, cotton or gauze being fastened in its apex, on which the ether is poured. Begin with a drachm; let the patient get accustomed gradually to the ether, diluting it well with air by holding the inhaler an inch or so from the face and gradually approaching. In that way, the feeling of suffocation is avoided. As the patient approaches unconsciousness, hold the mask closely so as to shut out the air, and the stage of anesthesia will be quickly reached without excitement.

If one proceeds timidly at this stage, the anesthesia will be hard to obtain and much .more ether will be required. Once the reflexes are abolished, use small quantities, frequently applied. The "drop method " may be employed with ether as well as with chloroform, and reduces the danger to the minimum. The accident most to be feared is respiratory paralysis.

The signs indicating the favorable progress of ether anesthesia during the operation are: pulse full and regular; respiration deep and slightly snoring; face flushed; and pupils slightly dflated. Cyanosis is the signal for more oxygen. Any disturbance of the respiration demands

ACCIDENTS OF ANESTHESIA. 13

immediate attention. For excessive mucous formation Ford recommends spraying on the mask at intervals of five or six minutes when necessary an adrenalin solution. Three parts of water to one part adrenalin solution (i-iooo> are used in an ordinary atomizer. Ford claims that it also acts as a circulatory stimulant.

TREATMENT OF THE ACCIDENTS OF ANESTHESIA.

Certain measures are recommended as forestalling the dangers, of anesthesia though they are, as a rule, more appropriate in the general surgery of hospitals.

A preliminary gastric lavage will save embarrassment in certain cases. A preliminary subcutaneous injection of normal salt solution wdll sustain the patient in the cases of anemia and grave septic infection.

Many surgeons precede a chloroform anesthesia by hypodermic injection of morphia or strychnia. None of these methods lessens the anesthetist's responsibility and duty to watch every point.

If the circulation grows weak, the pulse small, rapid, compressible, due to the effect of the anesthetic agent and not to shock or hemorrhage, withdraw the agent and lower the head, draw out the tongue and begin artificial respiration, and the danger is usually soon passed.

Hypodermic injection of stimulants, such as strychnia or camphorated oil, often do good under these circumstances ; but when the circulation is paralyzed and syncope has supervened, their use is illusory. Do not w^aste time preparing them, though an assistant may do so, but proceed to make rhythmic traction on the tongue, and artificial respiration, both being carried out methodically. If an assistant is at hand, carry out the two measures simultaneously; otherwise, try the tongue traction first or at least get it pulled out well. Traction of the tongue to do good, must be rhythmic. The tongue must be caught up carefully with forceps and no force must be used. Often the tongue is seriously injured by the feverish pulls of the agitated operator, who has quite forgotten that the maneuver is effectual only when rhythmic. Likewise, the artificial respiration must be rhythmic.

Grasp the patient's elbows and draw them gently and steadily up-

ANESTHESIA.

ward until they meet above the head. The pectoral muscles are put upon" the stretch and the chest expanded and respiration produced. At the same time the tongue is drawn outward (Fig. i).

The arms are next brought with a steady movelrftht to the chest

Fig. I. — Stage of inspiration. Tongue shouiva be drawn out with this movement. (Stewart.)

wall and the diaphragm compressed. (Stage of expiration.) At the same time, the tongue is permitted to retract (Fig. 2).

These movements are to be repeated at the rate of about twenty

Fig. 2. — Stage of expiration. Tongue permitted to drop back in mouth. (Stewart.)

per minute and should be persisted in without intermission for at least a. half hour before giving up hope of resuscitation.

Direct compression of the heart is a procedure of real value and it may often be readily managed through the abdominal walls. In the

LOCAL ANESTHESIA.

case of abdominal operations, the hand may be passed up to the diaphragm and the heart seized and kneaded in that manner.

Other forms of general anesthesia will not often be of service in emergency practice for obvious reasons, however valuable they may otherwise be. It is hardly necessary, therefore, to consider nitrous oxide or ethyl chloride and their congeners.