tal infusion of normal saline solution is indicated. Transfusion of whole or defibrinated blood has been for substantial reasons abandoned. Impending death from hemorrhage can often be prevented by restoringintracardiacan l intravascular pressure to a degree compatible with their physiological necessity by the use of saline solution administered by any of the routes indicated. In the after-treatment of hemorrhage the administration of some preparation of iron and concentrated nourishment fulfill the most important indications.

Wounds. A comprehensive knowledge of the processes by which wounds heal and the conditions which are necessary to secure healing by primary intention, a mastery of the principles and practice which govern their modern treatment, are necessary to the successful treatment of emergency cases. The emergency surgeon must of necessity be prepared to treat infected wounds, as every accidental wound must be regarded and treated as such. The emergency surgeon must practice antiseptic surgery. He will be successful in proportion as he succeeds in transforming infected into aseptic wounds. He will soon satisfy himself that the antiseptic which will prove most reliable and useful is carbolic acid in solution, varying in strength from one to five per cent., according to the age of the patient, the size and character of the wound, and the length of time that has intervened between the receipt of the injury and the first aid. He will select the kitchen as his best dressing and operating-room. Here the instruments can be sterilized by boiling, and in the absence of proper dressing material a supply can be obtained almost anywhere by boiling for a sufficient length of time towels, napkins, sheets, pillow-cases, etc., which can always be sterilized and used as a safe dressing. The kitchen table is usually best adapted for the surgeon's use. Saline solution, so useful in cleansing recent wounds prior to disinfection, and so often employed in the treatment of shock and serious hemorrhage, can always be prepared here and kept at a proper temperature ready for use. This is the place also to find the receptacles for solution and their sterilization. The disinfection of a recent wound consists in shaving and scrubbing with hot sterile water and soft soap far beyond the limits of the wound over a surface which will correspond with the size of the dressing to be applied, the removal of all foreign substances, and finally by irrigating the wound with a carbolized solution of appropriate strength to meet the existing indications. Lacerated wounds should be transformed as nearly as can be done into incised wounds by trimming margins and removing shreds of tissue injured beyond all possibility of recovery. Recent gunshot wounds should be interfered with as little as possible. Probing for bullets, on the whole, does more harm than good. The external wound or wounds should be disinfected as well as their margins for some distance, and the first aid dressing containing an antiseptic powder applied and allowed to remain until the wound has healed, or until unmistakable symptoms indicating infection make their appearance. Suturing of an accidental wound requires special care. With absorbable buried sutures anatomical structures of the same kind are to be united. Severed tendons and nerves are sutured separately as well as muscles and fascia. Careful hemostasis adds much to the probability of obtaining union by primary intention. In the care of large wounds silkworm-gut is used in preference to any other material for deep sutures, which should be made to include the floor of the wound as well as the entire margins, so as to prevent the formation of so-calle.l "dead spaces." Wounds of the scalp, face and lips seldom require drainage. Accidental wounds in other parts of the body usually require drainage for a sufficient length of time to prove whether or not the wound is aseptic. Tubular, gauze and catgut drains are employed according to the size, location of the wound and probability of the occurrence of suppuration. Dry hygroscopic dressings are preferable to moist dressings in the treatment of recent wounds. Rest for the injured part is necessary to aid nature's resources in effecting ideal healing by primary intention, and must be secured by bandaging and in wounds of the extremities by the use of well-padded splints. The injured part is dressed in a position which will insure relaxation of the severed structures. An aseptic wound is, as a rule, a painless wound. If pain sets in, it is an indication that infection has occurred, or that something is wrong, and instead of dulling the pain by the use of anodynes, the careful physician removes the dressing under aseptic precautions, examines the wound, seeks for, and removes the cause of the pain. In the management of wounds that exhibit local signs or general symptoms of infection, suturing is contraindicated, and anything which increases tension must be carefully avoided. The mechanical treatment in securing relaxation of the injured tissues and approximation of the wound margins consists largely in the use of position, splints and bandages. It is in such cases that the moist hot antiseptic compress takes the place of the dry dressing. The solutions that are safe and efficient under such circumstances are: Saturated solution of acetate of aluminum, Thiersch's solution, saturated solution of boracic acid, and a solution of one to one thousand either of the citrate or lactate of silver. Over the compress an impermeable cover of gutta percha, mackintosh, or protective silk is applied to retain heat and moisture. Infected wounds necessarily require free and ample drainage. Burrowing of pus must be looked for and promptly met by establishing effi

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cient tubular drainage. In the treatment of all suppurating affections the tubular drain is far superior to gauze drainage. After suppuration is under control secondary suturing often proves of value in hastening the final proeess of repair, but more frequently the same object is attained by the use of broad strips of adhesive plaster applied over the dry dressing with which the wound margins are approximated. In large surface defects skin trans-plantation by Thiersch's, Reverdin's, Wolfe's, or Hirschberg's method is resorted to for the purpose of hastening healing by cicatrization, epidermization and with the object in view of securing the best possible substitute for the normal skin lost by the injury or the subsequent destructivecomplication. Nature requires time to repair an injury. Much harm has been done by abandoning the mechanical supports too soon. In wounds of the scalp, face and lips: the sutures are superfluous after three to five days; in all other parts of the body they should not be removed in less than two weeks, provided the wound is aseptic. In pene-trating wounds of the abdomen, accidental and intentional, the patient must be confined to bed at least four weeks, as any deviation from this rule in favor of an earlier convalescence is very liable to be followed sooner or later by the development of a ventral hernia.

Dislocation. In the reduction of dislocations, recent and ancient, the practitioner must bear in mind the importance of relaxing the untorn portion of the capsular ligament in all efforts by manipulation or traction. The administration of an anesthetic renders invaluable service by effecting muscular relaxation. The cardinal rule to bring the dislocated bone in the same position it occupied at the moment the accident occurred should never be forgotten, as it furnishes the keynote to successful reduction without inflicting additional damage to the injured joint. All

successful rational methods are based on this principle. The practitioner must study the anatomical relations of the dislocated bone before he makes any attempt at reduction, and must be guided by them in making his efforts to replace it by manipulation or traction. Every dislocation is complicated by extensive injury to the soft structures of the joint which, like any other wound, requires time for complete repair. After reduction has been effected, the injured joint should be immobilized for at least three weeks to insure satisfactory repair of the ruptured ligaments. Stiffness and limited range of motion of the injured joint are more liable to occur if premature active and passive motion are advised and practiced too soon, rather than if a sufficient length of time is allowed for the repair of the injured joint, to say nothing of the danger of the occurrence of habitual luxations, which are seen only too often in cases in which the patient has not been cautioned to provide rest for the injured joint for a sufficient length of time to complete the repair of the lacerated ligaments.

Compound Fractures. - Compound fractures may be classed among the serious injuries which come under the care of the emergency surgeon. It is in such cases that prompt attention and skillful treatment yield the most gratifying results. The modern treatment of wounds has done everything in minimizing the dangers of open fractures. The great loss of limbs and lives incident to these accidents before antiseptic and aseptic surgery were practiced was due entirely to wound infection and its consequences. The modern treatment of the wound complications has succeeded in the great majority of cases in transforming practically an open into a closed fracture in all recent cases. The emergency surgeon recognizes two varieties of compound fractures in determining upon the plan of treatment to be pursued: