I drew attention to some of the leading features of the method of local analgesia which has of late been practised in many parts of the world. Since then I have given the procedure a fairly extended trial and on the basis of all the cases treated in this way by myself during the year 1899 I venture to offer some further remarks upon the subject. In the first place, it may be stated that all the patients enumerated below, except one who was delirious, elected after due explanation to have the

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... ration performed under local analgesia. Any who objected decidedly were not urged to have it. A good many expressed a strong desire for it either because they had a dread of general anxsthesia from previous experience or for other reasons. I believe that I am correct in stating that not one of those who were operated on under local analgesia alone regretted it. And it may further be stated that several who had had a previous experience of chloroform or ether and for subsequent operations selected eucaine j8, expressed themselves as more than pleased with their choice. Some of these latter had, for instance, had one radical cure for hernia done under general anaesthesia and the other on the opposite side under local analgesia, other conditions being equal. The first point which comes out of a study of our series is the fact that no ill-effect has followed the use of the normal saline solution with 1 in 1000 of eucaineb added to it which has been employed for local analgesia. Not only have no toxic troubles arisen, even when five or six ounces of the solution were used, but the primary union of the wounds has not been in the least interfered with. The only thing which I have noticed as possibly a specific effect of the drug was free sweating in several cases and pallor in a few. But this might have been due to other causes, as also that a very few of the patients vomited during the operation, and I think it was. In long operations I have sometimes used as much as six ounces of the solution and certainly without any ill-effect. This is only what one would expect from the harmlessness of even larger quantities given to animals. But if it is quite clear that there is little, if any, immediate or subsequent ill-effect from local analgesia produced in this way it is equally plain that there are certain limitations to its use. Children, for instance, appear to be unsuitable subjects for this procedure. The mere sight of the surgical preparations for operation frightens them and their unstable emotional condition is upset by the slightest pain. Very timid adults for the same reason are also better dealt with by general anaesthesia. If the part to be operated on is acutely inflamed I have found it very difficult, if not impossible, to render it quite insensible to pain, although in one case of typhlitis and general peritonitis I find it noted that from beginning to end of the operation there was no trace of pain, though the patient showed no evidence of blunted feeling otherwise. Again, it must be remembered that this procedure only causes local analgesia and in many operations it is next to impossible to render insensible all the structures which may be affected by the manipulations of our operation. For this reason when the intestine is being resected it is necessary to avoid all drag upon the mesentery which is beyond the reach of the injection, otherwise the patients state that they have a feeling as if the abdomen were being " pressed upon" or they may say that there is griping. In one case of posterior gastro-enterostomy, for instance, which was on the whole borne by a delicate woman extremely well the necessary lifting out the stomach for diagnosis produced this feeling and even vomiting. When the organ was 1 THE LANCET, Feb. 4th, 1899, p. 282. allowed to slip back the rest of the operation was completed without any pain at all and the patient made an excellent recovery. Again, in operating for the radical cure of inguinal hernia, of which I have had many cases, I have noticed that if the cord is much dragged upon the strain is productive of great discomfort, but that if it is fully injected as high up as possible and separated from the sac without dragging no pain is complained of. This also applies to the omentum and sac and I have often asked the patients to note particularly when I was ligaturing these structures and cutting them off, and they have told me that they felt nothing. The same was seen well in three cases in which I have recently operated for the removal of considerable thyroid adenomata of the size of an orange. The incision, a large one, and the subsequent dissection were painless, but on drawing out the tumour to get at the last deep attachments the patients stated that there was a °' presaing " sensation in the neck. It was not severe, but was worth noting. In one other similar case of thyroid disease where there was a good deal of bleeding, and where it was necessary to hurry, I gave chloroform for the last part of the operation. There is another drawback to this method which deserves notice if only to show that it is a trifling one. When the fluid is first injected the result is to produce a distension for a time of the areolar spaces, so that an appearance of artificial oedema is seen. This undoubtedly makes the first dissection less clear for the moment. This con. dition does not last long as the fluid trickles out of the wound and I have come to disregard it altogether. But to the beginner it is disconcerting to some extent. Another point, too, deserves notice in reference to the actual dissection. If this is carried out by rapid cuts or snips with scissors the moment of division of small vessels is felt as a twinge, whereas if the cuts are made more deliberately with knife and scissors nothing is felt as a rule. All these facts tend to diminish the rapidity of operation somewhat, which is a drawback from the surgeon's point of view. But this is compensated for to the patient by the absence of sickness after the operation and the fact that he can enjoy food in many cases at once, indeed many have enjoyed their cup of tea during the operation. The cases which appear to be most suitable for this procedure are those in which there is considerable danger of lung complications following the use of chloroform or ether. In intestinal obstruction, for instance, in weak or elderly persons this is peculiarly the case. They have often suffered for days from stercoraceous vomiting and have been recumbent and will have to remain so. In such cases no one can deny the danger of keeping them for a long time under the influence of general anaesthesia, especially as they will often be sick after recovering from the anaesthesia and consequently cannot be fed or stimulated by the stomach. In such cases the local analgesia answers admirably, and I have no hesitation in urging these patients to it if they are not strongly opposed. Again, a colotomy or resection of gut under these conditions is a typical case in point and such patients will thank the surgeon afterwards for having spared them the use of chloroform. Quite recently I have done a colotomy on a lady in the country who dreaded general anassthesia. Under eucaineb she felt, she said, practically nothing of my manipulations from the first cut to the last stitch and was very grateful for the local analgesia, as she had experienced the unpleasant effects of the general anaesthetics on several occasions in former years. Again, in cases of empyema, where it is often questionable whether chloroform or ether will be safe, I have found local analgesia very satisfactory. But here it must be remembered that in the deeper structures hypersesthesia will be present owing to the inflamed state of the pleura and costal periosteum. It is necessary then to be very careful in injecting very fully the whole area of the deeper structures to be,dealt with. And even so, perhaps a little pain will be felt as they are divided. But this is a small price to pay for the avoidance of the illeffects of chloroform or ether in such cases. In two cases now in my wards operated on for empyema on phthisical patients this is well illustrated and the patients if asked will give a very good account of the procedure. In one other I had to complete the operation under chloroform as a piece of rib had to be excised. But there is no doubt that the method requires considerable practice on the part of the surgeon before he can obtain the best results. This I can vouch for after carefully working at it for more than a year and a half, during which a considerable variety of cases have been treated by it. It is