for double pyosalpinx and appendix removed at the same time. Made an uneventful recovery.

About one year afterward, complained of pain in the region of the rectum, extending up into the posterior cul de sac, and painful defecation, and at times passing large quantities of blood. The symptoms becoming more aggravated, she was sent to the hospital and under ether anesthesia I found a small fibroid in the posterior wall of the uterus, and a large mass the size of a navel orange a little above the posterior cul de sac. On opening patient up, dissecting down through quite dense adhesions, found the tumor, which I first thought was a solitary cyst; trying to dissect it loose from its bed, it ruptured and quite a large quantity of black blood and fecal material came out. After dissecting the mass loose, we found it to be the first portion of the ileum. I then resected about eight inches of this diseased portion of the bowel, doing an end to end anastomosis by the ligature method, throwing the omentum down over the line of union, so as to wall off any leak. age which might occur from the general abdominal cavity. Drainage was

335

instituted for 48 hours and then removed.

Patient made an uneventful recov

ery.

The section of the bowel which was removed showed an ulcer, which had eaten its way through the wall of the bowel to the peritoneal coat and then allowed the blood and liquid fecal material to dissect up the peritoneal coat, forming a tumor the size of a large navel orange. This pathological specimen shows how persons can go around about their business and their life hang

ing by a thread without much physical suffering, for had this bowel ruptured, being in the position it was and not being completely walled off from the general peritoneal cavity, it would probably have cost her her life unless she was where she could have been

properly handled at once. Taking into consideration what the previous operation had been, it would have made the diagnosis very difficult.

The symptom which worried the patient the most was the hemorrhages from the bowel, the pain at the time and for a period after the bowel move

ments.

Since the discovery of ether in 1846 by Morton, and chloroform in 1847 by Simpson, and nitrous oxide by Wells in 1884, surgical operations have been made relatively very safe and comfortable, and have made possible the wonderful achievements of surgical endeavor. The reported mortality from these agents is extremely low, almost a negligible quantity, yet we must believe that there are many fatalities that are directly due to the anaes

thetic that are not reported, and these are occurring in every nook of the world; e. g., Dr. C. G. Parsons, expert anaesthetist, of this city, has kept a record of all deaths coming to his knowledge in hospitals of this city in the past eight years. During that time thirty-five deaths have been recorded by this observer. I have estimated that during that time 40,000 anaesthesias have been administered, allowing 1200 as the yearly average for each of the

three largest and 1400 in the others annually. This would give a mortality of one to each 1150 administrations during the course of the operation and not due to the gravity of the operation. If to this we add those cases of death due to complications directly traceable to the anaesthetic, such as most postoperative pneumonias, anaesthetic shock, urinary suppression and fatty degeneration of the liver, regardless of the morbid conditions recently claimed to follow in the wake of these drugs, we are forced to the real dangers to the patient as being well within the small percentage column of each one hundred cases. However, these figures are not sufficiently classified to be accepted as final, but they are approximately correct, which figures are really quite astounding, for we usually assure our patients that there is practically no danger in such and such a procedure, or that the only danger is in the anaesthetic and that is so slight as to be negligible; all of which, we must admit to ourselves is entirely too sanguine.

During the last decade there has been no phase of surgical progress so notable or so important as the advancement made in the use of local anaesthe sia in both minor and major surgery, and I feel that American surgeons have not kept up with those of Continental Europe; and I also feel that the profession of this region is still slower in the adoption of the method. To be sure of this, you need only to go over the records of our hospitals for a short time to be convinced of that statement. I will venture to assert that fully 25% of all work could be done in this manner if only the surgeon would perfect himself in the technique of the method, and unbiasedly present the relative advantages to his prospective operative patients, and too, in such a manner as to convince the patient that he could do it, thus relieving his fears. I dare say that very few eases where it was ad

vised would refuse to have the operation by the safer method.

Local anaesthesia was really introduced by Koller in 1884, with cocaine upon the mucous membranes, yet cocaine has had a good many fatalities, most of them previous to the additional use of adrenalin and when it was used in stronger solutions. This is true of all anaesthetics, locals as well as general, and the recent step in the former is to use weaker solutions all the time, and too there has resulted a more uniform method of administration; e. g., all, or nearly all use the weakest solution in the skin, and only slightly stronger in the deeper tissues; however, some yet use very strong solutions in the skin, as much as 4%. This we believe to be entirely wrong, for it is possible to anaesthetise the skin with pressure infiltration of sterile water, and besides the more of the drug you use in the skin the less you are free to use in the deeper tissues.

At the same time the field of local anaesthesia has been widened from minor operations to many of the most difficult operations in surgery. The skull has been trephined and the brain examined, explored or operated on. The kidney has been anchored or removed; the abdomen has been opened, explored, or its organs operated; e. g., gastro-enterostomy, intestinal anastomoses and resections, gall stones removed or the gall bladder drained, appendectomies, herniotomies, the urinary bladder opened and stones removed; thorocotomy. These have all been done many times, and it is surprising how easy some of them are to accomplish. Fingers and toes are not difficult to do anything necessary upon; also- thehands and feet, and the whole limb can be handled very satisfactorily by intravenous method as developed and used mainly by Bier. The breast may be amputated, but the glands of the axilla are difficult to completely re

move. After such an array of difficult operations it is almost useless to mention those minor ones, as circumcision, varicocelectomy, orchidectomy, lipomectomy, sebaceous cysts, nevi, warts, moles, removal of glands for examination or cure. In fact, we would have to enumerate the whole list of surgical procedures, that may be done, either from indication or from choice.

Yet how often do we see a general anaesthetic given for almost the simplest of all minor operations. I wonder if at times it is not done to magnify the importance of the procedure, or even I am inclined to suspect that the financial side creeps in. I recall seeing a man given ether for the opening of an abscess which had already burrowed almost through the skin. It was simply punctured and a small gauze wick inserted, a wholly simple procedure. My curiosity impelled me to ask if it could not have been opened under a local anaesthetic; and I was astounded to hear his reply-"Sure, but had I done it that way, I could not have charged him more than $15.00 or $20.00, while this way he is willing to pay $75.00 or $100.00.

However that may be, I feel that we owe it to our patients and to ourselves to surround each patient with every safeguard possible, that we owe it to them to give sufficient of our time to make it the safest operation possible for the relief of the difficulty; I mean that even if it should take a little longer to do an operation under local anaesthesia, we should select that method. We cannot honestly offer the excuse that we are too busy, for there is not one of us who could not do twice as much as we are doing, and yet have time for recreation. I am very sure that it requires more skill, patience, gentleness and deftness in dissecting, to operate under local anaethesia than under general. I am also very sure that under general anaesthesia there

is too much rough and unnecessary handling of the intestines; that they are unnecessarily pulled upon, and other structures maltreated by hurried operators, who are working for one end only, that of reducing the time of operation-almost the least important thing in the vast majority of cases, it certainly does make a difference when the extra time is expressed in hours or half hours, but not any difference when only a few minutes are gained at the expense of gentleness with the tissues or thoroughness in investigation of related or adjacent structures. The day for the slam-bang, cursing piratical surgeon is past, whose skill was judged more by the size of his biceps or his ability to swear in seven languages, than upon his equilibrium of temper and tenseness of his mental concentration-who is able to do, as we have seen in certain clinics, from three to eight major operations every day of the week and month and for ten months of the year, and not get tired or turn the operating room upside down.

The operating room must be conducted differently, there can be no foolish questions asked, each assistant must know your technique and give every possible aid without having to be directed, the tissues must be handled carefully, no retractor is to be yanked or pulled upon, unnecessary noise of instruments must be avoided. The patient may be diverted by interesting conversation and his mind given reassurance at all times. Convince him that it is not necessary nor desirable for him to endure any pain; that if he has a twinge he shall tell you, and that you can and will remove that chance. You may be able to proceed with the operation for a long way before he is aware that you have begun, provided you are. not trying to operate as you do under general anaesthesia; that you do not lose your temper and thus destroy the patient's confidence, for even the little child soon learns that the real master

does not resort to seeming violence to control a situation.

Indications: With every new thing proposed there is always opposition offered, and too often the objection is made, perhaps unconsciously, because we cannot do that thing ourselves or because of prejudice. This, as in everything else, the individuals must be taught its advantages, and how slow it is at times. There has never been, we believe, so much said, and written upon any one subject, as upon appendicitis. and yet today approximately one-half of the cases are ruptured before being brought to the operating table.

To put it concisely, I would say that local anaesthesia is indicated in all cases where the necessary operation and examination can be done. It should be remembered that a general can always be given if you are unable to finish under a local; in this way you will be at least able to reduce the time of anaesthesia by half in bad cases. You can do considerable manipulation, inside the abdomen, if you do not exert more pressure upon the organs than they are accustomed to from the usual intra-abdominal pressure while we are lifting or straining; and this is sufficient, these examinations can be made from the usual incisions. The method is especially indicated in the aged, and is a gift to those suffering from herniae, who have preferred to suffer rather than to try the risks and dis comfort of general anaesthesia, and it will be used more in these for gall stones; also indicated in advanced or active cases of tuberculosis, or in arteriosclerosis, or in low kidney function and in certain heart lesions-compensated valvular lesions do not contraindicate general anaesthesia. should always be used in phlegmonous abscess in the neck of fat people, for they are certainly very bad risks under general. Where the infiltration method is not satisfactory, the intravenous

Locals

method may be used instead satisfactorily.

I have used it with good results upon children as young as seven years for circumcision, and in one case, circumcision, in a child eighteen months old. The child did cry, but his crying bore no relation to the work, for he was perfectly quiet while suturing, and cried at times when nothing was being done. I have used it in herniotomies in nervous Jewish men, without a preinguinal and femoral hernia in women, vious opiate. I have also used it in both of whom had been previously operated for other things with a general anaesthetic and one with an unsuccessful local anaesthetic, both as to anaesthesia and to relief, and each asserted afterwards that if it were necessary for another such operation that she would select the local without hesitation. I have operated one side of a double hernia, in two instances, and then asked if they wanted the other one operated at once, and they both said to go ahead. It is a great pleasure to have a patient eat his breakfast, then be brought to the operating table, have a major operation done and be taken back to his room and eat his lunch, and to know that outside of the local trauma, he is fully as normal as when he came to the operating room.

I am convinced that the personal equation of the surgeon is a considerable factor in preparing the patient mentally for the procedure, and to hold his confidence during the operation. I am also convinced that the doctor is often responsible for nervous, fidgety, worrying patients, in that they may show undue alarm or make unnecessarily bad prognoses or give the patient too much personal attention, or encourage frequent repetition of their various real or supposed ills. These all tend to unfit the individual for any exhibition of strength of character.

Methods of Administration: Local anaesthetics are used mainly in three

ways: (1) By infiltration of the tissues without regard to nerve trunks, but to inject enough of the solution so that the nerve endings and the smaller nerve trunks will be sufficiently anaesthetized, both from pressure and from the drug. This has been criticised that it may cause sloughing, I can say that the only sloughing I have ever seen was in one case only, due to too much adre nalin solution being used in the skin. (2) By blocking the nerves that supply the region of operation, with or without infiltration in the immediate region. I rely very much upon blocking the nerve trunks whenever practicable, and I use the weak solutions instead of the very strong ones previously advised, for a 0.5% solution is just as effective, if properly injected, as a 4% solution. (3) The intravenous method, as used more by Bier to date. First, get all the blood out of the limb by a spiral elastic Martin bandage from the distal portion, then apply a tourniquet at upper portion, then remove the spiral bandage, place another tourniquet several inches below the upper on; or if you desire to operate at the extreme portions, the second tourniquet may be omitted; then open a superficial vein and inject as for intravenous salt solution, from 100 c.c. to 200 c.c. of 0.5% novocaine, novocaine, without without adrenalin against the valves. In fifteen minutes, go ahead; when through, remove the tourniquets gradually to prevent too rapid absorption. Bier reports its successful use in 135 cases. The method is a good one and to be used where local infiltration is not sufficient. Some men recommend a tourniquet in each instance, where it can be applied; e. g., at the root of the penis in cicumcision; this is necessary if you do not use adrenalin with the solution, to prevent too rapid absorption. The amount of anaesthetic that can be safely used depends upon the rapidity with which it is injected and the rate of absorption. If the injection covers a period of from a

half hour to an hour, you may safely use much more, perhaps more than twice a much as if you injected all parts before beginning the operation. In this manner a part of it is lost from the tissues, more of it has been oxidized by the tissues, and now you can inject more at any time you desire. Some men endeavor to inject all at once and then hurry through the operation; personally, I prefer to inject only a part, if it is a major procedure, and proceed as far as injected, then to inject more as that region is passed. I appreciate that this lengthens the time, but I am sure that it gives a more satisfactory result in every way, as better anaesthesia may be obtained by the greater amount you are able to use. Of course, with smaller operations the entire area is injected at once. It is my custom to inject a double row of wheals in the skin, and then make the incision between them. In this manner the skin is still nicely anaesthetised at the end of an hour or longer. There is no pain in the visceral peritoneum, but pulling upon the omentum or mesentery gives much pain and this must be avoided; it is better, if necessary to enlarge the incision. Bones may be drilled, chiseled or cut if the periosteum has been anaesthetised or removed. The brain itself is without pain, and operations of some magnitude can be done upon it with local anaesthesia. I feel that any patient may be so convinced of its advantages, that he will select the local, provided the situation is put to him in the right light, and that consciousness while being operated upon is not nearly so objectionable to most normal individuals, as the most unpleasant knowledge that you. are losing consciousness with a general, with the ever present thought that you may be the rare case that does not recover from the anaesthetic; and too, you can assure the patient that the local will remove practically all dan