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Routine method of artificial respiration for the surgical clinic
ROUTINE
ARTIFICIAL
RESPIRATION W. WAYNE
METHOD
OF
FOR THE SURGICAL CLINIC *
BABCOCK,
M.D.,
F.A.C.S.
PHILADELPHIA
A
SPHYXIA during an operation, as a ruIe, is not convenientIy or effectiveIy treated by the routine methods of artificia1 respiration. Measures used in civi1 or industria1 practice are adapted to the patient on the fIoor or ground rather than to the one on the operating table. The surgeon does not care to climb upon the operating tabIe and bestride an open abdomen for the Howard method even though the viscera are covered by towels, or much Iess to invert the patient for the procedure of Schafer or Marsha11 HaII. The arm movements of SiIvester interfere with venocIysis and observations as to the movement of tida1 air to and from the thorax. The tongue traction of Laborde is unreIiabIe and if used, a dangerous deIay in adopting adequate measures for artificia1 respiration may resuIt. In the surgica1 emergency there shouId be no delay, and the patient shouId remain on the operating tabIe with the least possibIe change in position. The method shouId be positive and effective, and the manipuIations used shouId not prevent convenient access to the mouth and jaws to maintain an open airway, toconstantIy record the tida1 air movements and to give, if desired, inhaIations of ammonia, oxygen, carbon dioxide or other substance. ArtificiaI respiration is not a gesture, it is an effect; and the surgeon should have constant evidence of its effectiveness. It shouId be feasibIe without producing infection, or causing other danger through an open abdomina1 cavity. It should not interfere with a coincident intravenous injection into a vein of the arm. If possibIe, it shouId permit the associated use of cardiac massage. The danger of fracture
of the ribs from undue pressure upon the thorax shouId be minimal. It is our observation that in the operative emergency, the surgeon usuaIIy resorts to the SiIvester method, driving the anesthetist from the patient’s head, as the patient’s arms are moved vioIentIy up and down; thus a carefu1 contro1 of the jaws and tongue, the accurate observation of the air movements, and the convenient use of intravenous injection are prevented. Experience has convinced me that this is an undesirabIe method for use in the surgica1 cIinic and Iike the puImotor shouId pass into innocuous desuetude. For over twenty years we have used the foIIowing routine. If cessation of respiration is feared or occurs, the anesthetist affixes a deIicate wisp of cotton by a bit of adhesive pIaster or coIIodion to the tip of the patient’s nose. This hangs in front of the patient’s nose and mouth and is a positive indicator of spontaneous or induced air movements. The patient’s arms are extended aIongside his head. A Iarge pad is pIaced in the abdomina1 wound to prevent the extrusion of intestines, and the abdomen and chest are covered by a steriIe tower or sheet. If the cotton indicator remains motionIess, the operator standing on the right side facing the patient’s head, cIasps his hands together over the manubrium of the patient, his eIbows and forearm coapting the IateraI thoracic waIIs. With press&e of the hands, forearms and eIbows back, down and in, aided to some degree by the weight of his body, which is swung upon the patient’s chest, the operator produces expiration, at the same time watching the patient’s face and noting the effect
* Submitted for publication August 19, 1931. 221
222
American Journd of Surgery
Babcock-ArtificiaI
of his pressure upon the cotton indicator. The effect may be aided by pressure from the hands of an assistant pIaced
Respiration
Awusr.
193,
as it enters and Ieaves the patient’s chest. To forestah circuIatory faihrre, it is wise for an assistant to promptIy start an
FIG. I. ArtificiaI respiration by intermittent compression of anterior thoracic wall. Patient’s arms extended alongside head. Operator’s hands are clasped over patient’s sternum, and expiration, proved by cotton indicator affrxed to patient’s nose, is produced by downward, backward and inward pressure with hands, forearms and elbows. Meanwhile epinephrinized saIine, guided by reaction upon puIse, is being given.
under the operator’s eibows. Inspiration, of course, resuhs as the pressure is sharpIy reIeased. The anesthetist maintains an open airway by keeping the mandibIe and tongue forward, notes the movements of the tida1 air produced, watches the pup& and the carotid, tempora1 or radia1 p&e and is prepared to administer carbon dioxide oxygen, or other restorative. Nothing shouId be given by inhaIation, however, unti1 the operator has proved that he can produce adequate movements of air to and from the patient’s Iungs. The cotton indicator is invaIuabIe in showing the efficiency of the operator. For exampIe, in a case in which a patient was kept ahve for about five hours by the method, using reIays of assistants and medica students, I found that certain men were unabIe without specia1 training to move the tida1 air. The anesthetist watching at the patient’s head and maintaining an open airway by mouth gag or tongue forceps, shouId not onIy see the cotton move but aIso hear the rush of air
injection of epinephrinized sahne sohrtion into a convenient vein in the patient’s arm or Ieg. Compression methods for the production of artificial respiration, whiIe usuahy very satisfactory, at times wiII fai1. In certain patients with emphysema, a heavy barreI shaped chest, a pIeura1 effusion or extensive disease of the Iungs, it is not possibIe to produce artificia1 respiration by compression of the chest alone. The seniIe chest with caIcified Costa1 cartiIages has Iimited compressibihty. The same thing is occasionahy true even in chiIdren. In a young chiId and aIso in a heavy chested athletic young man, I was unabIe to sufhcientIy move the tida1 air, as shown by the indicator or by audibIe currents of air. In such a case what shouId be done? It is probabIe that the Silvester method or the Marshah-Ha11 method wiI1 aIso be ineffective, so therefore, we immediateIy abandon a11 compressive methods, and use forced inspiration by mouth to mouth insufhation. The operator steps to the side
NEW SERIES VOL. XVII,
No. 2
Babcock-ArtificiaI
of the patient’s head, compresses his nose with one hand and with the other makes pressure over his epigastrium to prevent
Respiration
American
J~WMI
0f surgery
223
otomy opening. Mouth to mouth insufllation has dispIaced the more comphcated methods of forced art&a1 respiration in
Frc. 2. If cotton indicator shows that sufficient air movement to and from chest does not occur from intermittent compression, mouth to mouth insulation is promptIy substituted. Patient’s mouth, hetd open by gag, is covered by four layers of gauze, and no&Is and stomach are compressed as operator intermittentIy infktes lungs. During inflation chest can be seen to expand; during expiration rush of escaping air is heard.
distention of the stomach by air. The patient’s mouth having been covered by two to four Iayers of gauze or a thin towei, the operator takes a deep inspiration, immediately appIies his wideIy opened mouth over that of the patient and makes forcible exhaIation. If properIy performed the patient’s chest will be observed to expand as the air is bIown into his mouth and at the end of the insufKlation, as the operator raised his head, a rush of air wiii be heard coming from the patient’s Iungs which is increased by an associated manual compression of the chest. For an aduIt patient, the mouth to mouth insulation is safe, as the pressure in the patient’s lungs cannot exceed or even equal that in the operator’s thorax. In children, however, care shouId be taken that undue pressure is not produced, remembering the deaths which have foIlowed the rupture of aIveoIi in infants or adults from the use of the pulmotor. In two cases, before we realized the effectiveness of simple mouth to mouth insulation, we produced forced inspiration by intermittently blowing through a tube pIaced over a trache-
our chnic, when the simpIe compression of the chest has failed, and has saved at least four Iives. But why not use oxygen or oxygen-carbon dioxide through the face prece of the anesthesia machine? Because it is not foo1 proof. In the desperate emergency there is no time to make sure that the machine is properly deIivering onIy pure oxygen and carbon dioxide in the right proportions. I saw one patient die from time Iost as the anesthetist insisted on proving how effective his apparatus was for purposes of resuscitation. Others may find as StanIey did, when it is too Iate to help the patient, that a nitrous oxide tank had been placed for that of oxygen. The operators’ Iungs are not subject to such error. They will dehver onIy oxygen and cnrbon dioxide. Usually it is necessary to use a mouth gag and occasionaIIy hold the tongue forward and to the angle of the mouth by a forceps, tenacuIum or thread during the insuffiation. An aIternative method of preventing the entrance of air into the stomach is to press the larynx back against the esophagus.
224
Amencan Journd of Surgery
Babcock-ArtificiaI
If tidal air is properly moved by the thoracic compression aIone, the operator and his assistant may maintain the steriIity
Respiration
AUGUST, 19x2
In respiratory failure and before the respirations have entireIy ceased a powerfu1 stimuIus may be obtained by the inhaIation
FIG. 3. If heart has stopped and does not respond to an intracardiac injectionof epinephrine, index finger is carried through a 2 cm. incision in third Ieft intercosta1 space and hooked about heart which is compressed and massaged
against overlying chest waI1. SteriIe wet gauze wrapped about
of gIoves and gowns, being ready to immediateIy compIete the operation or, shouId such prove necessary, to introduce the hand in the abdomina1 wound for cardiac massage. The respirations produced shouId not exceed a rate of fourteen to sixteen per minute. Methods of artificia1 respiration are seriousIy handicapped by regurgitant vomiting. The gastric secretions may flood into the pharynx or mouth and the patient be drowned by his own ffuids. I have seen one patient die from this cause. On the regurgitation of gastric Iiquids the head of the patient shouId be markedIy Iowered, and if Iarge quantities of Auid we11 into the mouth, as occurs in iIeus, a tracheotomy shouId quickIy be done and the respirations conducted through the trachea1 opening. Of course the danger of regurgitation may be reduced by gastric Iavage before the anesthetic is given, but at times the fluids continue to we11 back from the duodenum and the Iavage is insuffIcient.
baseof finger
prevents entrance of air into thorax.
of oxygen containing IO per cent of carbon dioxide. Such inhaIation shouId not prevent an earIy resort to artificia1 respiration when it is needed. In any case, the circuIation shouId constantIy be watched. The diffIcuIties of resuscitation are enormousIy increased by circuIatory faiIure and the patient wiI1 sureIy die if the heart absoIuteIy stops for more than seven minutes. An earIy resort to intravascuIar infusion with epinephrinized saIine insures against cardiac arrest, and an intravenous outfit shouId aIways be ready for instant use in every operating room. The smaIIest quantity of epinephrine soIution that wiI1 produce the desired effect (it may be x minim, it may be IOO minims of the I : IOOO solution) shouId be used. We start with 200 C.C. of saIine soIution containing IO minims of the standard I : IOOO epinephrine soIution. The instant the puIse responds, even though but a smaI1 fraction of the epinephrine has entered the vein, the flow is arrested to be resumed intermittentIy Iater as required. In this
.
NEW
SERIES VOL. XVII, No.
Babcock-ArtificiaI
2
way a prolonged effect may be produced. If there is no response the percentage of epinephrine in the saline is very rapidly increased unti1 a response is evoked. An excess of epinephrine is harmful, putting at times an enormous strain upon the heart and vesseIs and being foIlowed by corresponding secondary circulatory depression. With absolute arrest of the heart, a direct IocaI stimuIus is usualIy necessary to carry the epinephrine into coronaries where *it becomes effective. With the open abdomen subdiaphragmatic cardiac massage is easiIy produced. The operator shouId be carefu1 not to have the Ieft Iobe of the liver interposed between the interna hand and the diaphragm. In about 20 cases of cardiac massage the subdiaphragmatic method was the only one that gave me an enduring effect. OccasionaIIy, I have found it wiI[ fair where a transthoracic massage wiI1 stimulate the heart to action. It is not necessary to turn back a flap of the chest waI1 for transthoracic cardiac massage. A stab is made through the Ieft third interspace 2 cm. from the sternum (to avoid the internal mammary artery) the finger introduced into the chest as the knife is withdrawn and curIed about the Ieft border of the heart, which is rhythmicaI1.y compressed against the overly&g chest La11 by flexing the finger. The intraventricurar iniection of eDinephrine gives a vioIent stimuIus to t’he heart that is very effective and has IargeIy dispraced cardiac massage. A 22 gauge needle 9 cm. Iong is entered at the Ieft I
433
Respiration
American Journal of Surger)
225
border of the sternum in the third interspace, carried in and mesiaIIy unti1 the resistance of the venticuIar waII is past, aspirated to prove that the point of the needIe is in the free ventricurar cavity and the withdrawn bIood reinjected with the 3 or IO minims of epinephrine in the Luer syringe. These drastic procedures should rarely be necessary. During the period of dire emergency the subcutaneous injection of stimurants may divert the attendants from quicker and more effective measures. Therefore, we avoid them. FinaIIy it may be noted, that the need of an intracardiac injection during an operation usuaIIy indicates that the patient has not been watched with sufficient care, or that the proper prophyIactic measures were not instituted suffIcientIy earI?. SUMMARY I. The conventiona methods of artificia1 respiration are not we11 adapted to operating room practice. 2. The operator shouId use no method of artificia1 respiration that does not cause adequate quantities of air to enter and Ieave the patient’s chest. Artificial respiration is not a gesture, it is an effect. 3. Efforts at artificial respiration shouId be continued if necessary for man,y hours, or at Ieast unti1 the heart no Ionger responds to even the most powerful direct stimulus. The patient shouId be kept warm. 4. A time tested and effective pIan for routine use is here given.
ARTIFICIAL
RESPIRATION W. WAYNE
METHOD
OF
FOR THE SURGICAL CLINIC *
BABCOCK,
M.D.,
F.A.C.S.
PHILADELPHIA
A
SPHYXIA during an operation, as a ruIe, is not convenientIy or effectiveIy treated by the routine methods of artificia1 respiration. Measures used in civi1 or industria1 practice are adapted to the patient on the fIoor or ground rather than to the one on the operating table. The surgeon does not care to climb upon the operating tabIe and bestride an open abdomen for the Howard method even though the viscera are covered by towels, or much Iess to invert the patient for the procedure of Schafer or Marsha11 HaII. The arm movements of SiIvester interfere with venocIysis and observations as to the movement of tida1 air to and from the thorax. The tongue traction of Laborde is unreIiabIe and if used, a dangerous deIay in adopting adequate measures for artificia1 respiration may resuIt. In the surgica1 emergency there shouId be no delay, and the patient shouId remain on the operating tabIe with the least possibIe change in position. The method shouId be positive and effective, and the manipuIations used shouId not prevent convenient access to the mouth and jaws to maintain an open airway, toconstantIy record the tida1 air movements and to give, if desired, inhaIations of ammonia, oxygen, carbon dioxide or other substance. ArtificiaI respiration is not a gesture, it is an effect; and the surgeon should have constant evidence of its effectiveness. It shouId be feasibIe without producing infection, or causing other danger through an open abdomina1 cavity. It should not interfere with a coincident intravenous injection into a vein of the arm. If possibIe, it shouId permit the associated use of cardiac massage. The danger of fracture
of the ribs from undue pressure upon the thorax shouId be minimal. It is our observation that in the operative emergency, the surgeon usuaIIy resorts to the SiIvester method, driving the anesthetist from the patient’s head, as the patient’s arms are moved vioIentIy up and down; thus a carefu1 contro1 of the jaws and tongue, the accurate observation of the air movements, and the convenient use of intravenous injection are prevented. Experience has convinced me that this is an undesirabIe method for use in the surgica1 cIinic and Iike the puImotor shouId pass into innocuous desuetude. For over twenty years we have used the foIIowing routine. If cessation of respiration is feared or occurs, the anesthetist affixes a deIicate wisp of cotton by a bit of adhesive pIaster or coIIodion to the tip of the patient’s nose. This hangs in front of the patient’s nose and mouth and is a positive indicator of spontaneous or induced air movements. The patient’s arms are extended aIongside his head. A Iarge pad is pIaced in the abdomina1 wound to prevent the extrusion of intestines, and the abdomen and chest are covered by a steriIe tower or sheet. If the cotton indicator remains motionIess, the operator standing on the right side facing the patient’s head, cIasps his hands together over the manubrium of the patient, his eIbows and forearm coapting the IateraI thoracic waIIs. With press&e of the hands, forearms and eIbows back, down and in, aided to some degree by the weight of his body, which is swung upon the patient’s chest, the operator produces expiration, at the same time watching the patient’s face and noting the effect
* Submitted for publication August 19, 1931. 221
222
American Journd of Surgery
Babcock-ArtificiaI
of his pressure upon the cotton indicator. The effect may be aided by pressure from the hands of an assistant pIaced
Respiration
Awusr.
193,
as it enters and Ieaves the patient’s chest. To forestah circuIatory faihrre, it is wise for an assistant to promptIy start an
FIG. I. ArtificiaI respiration by intermittent compression of anterior thoracic wall. Patient’s arms extended alongside head. Operator’s hands are clasped over patient’s sternum, and expiration, proved by cotton indicator affrxed to patient’s nose, is produced by downward, backward and inward pressure with hands, forearms and elbows. Meanwhile epinephrinized saIine, guided by reaction upon puIse, is being given.
under the operator’s eibows. Inspiration, of course, resuhs as the pressure is sharpIy reIeased. The anesthetist maintains an open airway by keeping the mandibIe and tongue forward, notes the movements of the tida1 air produced, watches the pup& and the carotid, tempora1 or radia1 p&e and is prepared to administer carbon dioxide oxygen, or other restorative. Nothing shouId be given by inhaIation, however, unti1 the operator has proved that he can produce adequate movements of air to and from the patient’s Iungs. The cotton indicator is invaIuabIe in showing the efficiency of the operator. For exampIe, in a case in which a patient was kept ahve for about five hours by the method, using reIays of assistants and medica students, I found that certain men were unabIe without specia1 training to move the tida1 air. The anesthetist watching at the patient’s head and maintaining an open airway by mouth gag or tongue forceps, shouId not onIy see the cotton move but aIso hear the rush of air
injection of epinephrinized sahne sohrtion into a convenient vein in the patient’s arm or Ieg. Compression methods for the production of artificial respiration, whiIe usuahy very satisfactory, at times wiII fai1. In certain patients with emphysema, a heavy barreI shaped chest, a pIeura1 effusion or extensive disease of the Iungs, it is not possibIe to produce artificia1 respiration by compression of the chest alone. The seniIe chest with caIcified Costa1 cartiIages has Iimited compressibihty. The same thing is occasionahy true even in chiIdren. In a young chiId and aIso in a heavy chested athletic young man, I was unabIe to sufhcientIy move the tida1 air, as shown by the indicator or by audibIe currents of air. In such a case what shouId be done? It is probabIe that the Silvester method or the Marshah-Ha11 method wiI1 aIso be ineffective, so therefore, we immediateIy abandon a11 compressive methods, and use forced inspiration by mouth to mouth insufhation. The operator steps to the side
NEW SERIES VOL. XVII,
No. 2
Babcock-ArtificiaI
of the patient’s head, compresses his nose with one hand and with the other makes pressure over his epigastrium to prevent
Respiration
American
J~WMI
0f surgery
223
otomy opening. Mouth to mouth insufllation has dispIaced the more comphcated methods of forced art&a1 respiration in
Frc. 2. If cotton indicator shows that sufficient air movement to and from chest does not occur from intermittent compression, mouth to mouth insulation is promptIy substituted. Patient’s mouth, hetd open by gag, is covered by four layers of gauze, and no&Is and stomach are compressed as operator intermittentIy infktes lungs. During inflation chest can be seen to expand; during expiration rush of escaping air is heard.
distention of the stomach by air. The patient’s mouth having been covered by two to four Iayers of gauze or a thin towei, the operator takes a deep inspiration, immediately appIies his wideIy opened mouth over that of the patient and makes forcible exhaIation. If properIy performed the patient’s chest will be observed to expand as the air is bIown into his mouth and at the end of the insufKlation, as the operator raised his head, a rush of air wiii be heard coming from the patient’s Iungs which is increased by an associated manual compression of the chest. For an aduIt patient, the mouth to mouth insulation is safe, as the pressure in the patient’s lungs cannot exceed or even equal that in the operator’s thorax. In children, however, care shouId be taken that undue pressure is not produced, remembering the deaths which have foIlowed the rupture of aIveoIi in infants or adults from the use of the pulmotor. In two cases, before we realized the effectiveness of simple mouth to mouth insulation, we produced forced inspiration by intermittently blowing through a tube pIaced over a trache-
our chnic, when the simpIe compression of the chest has failed, and has saved at least four Iives. But why not use oxygen or oxygen-carbon dioxide through the face prece of the anesthesia machine? Because it is not foo1 proof. In the desperate emergency there is no time to make sure that the machine is properly deIivering onIy pure oxygen and carbon dioxide in the right proportions. I saw one patient die from time Iost as the anesthetist insisted on proving how effective his apparatus was for purposes of resuscitation. Others may find as StanIey did, when it is too Iate to help the patient, that a nitrous oxide tank had been placed for that of oxygen. The operators’ Iungs are not subject to such error. They will dehver onIy oxygen and cnrbon dioxide. Usually it is necessary to use a mouth gag and occasionaIIy hold the tongue forward and to the angle of the mouth by a forceps, tenacuIum or thread during the insuffiation. An aIternative method of preventing the entrance of air into the stomach is to press the larynx back against the esophagus.
224
Amencan Journd of Surgery
Babcock-ArtificiaI
If tidal air is properly moved by the thoracic compression aIone, the operator and his assistant may maintain the steriIity
Respiration
AUGUST, 19x2
In respiratory failure and before the respirations have entireIy ceased a powerfu1 stimuIus may be obtained by the inhaIation
FIG. 3. If heart has stopped and does not respond to an intracardiac injectionof epinephrine, index finger is carried through a 2 cm. incision in third Ieft intercosta1 space and hooked about heart which is compressed and massaged
against overlying chest waI1. SteriIe wet gauze wrapped about
of gIoves and gowns, being ready to immediateIy compIete the operation or, shouId such prove necessary, to introduce the hand in the abdomina1 wound for cardiac massage. The respirations produced shouId not exceed a rate of fourteen to sixteen per minute. Methods of artificia1 respiration are seriousIy handicapped by regurgitant vomiting. The gastric secretions may flood into the pharynx or mouth and the patient be drowned by his own ffuids. I have seen one patient die from this cause. On the regurgitation of gastric Iiquids the head of the patient shouId be markedIy Iowered, and if Iarge quantities of Auid we11 into the mouth, as occurs in iIeus, a tracheotomy shouId quickIy be done and the respirations conducted through the trachea1 opening. Of course the danger of regurgitation may be reduced by gastric Iavage before the anesthetic is given, but at times the fluids continue to we11 back from the duodenum and the Iavage is insuffIcient.
baseof finger
prevents entrance of air into thorax.
of oxygen containing IO per cent of carbon dioxide. Such inhaIation shouId not prevent an earIy resort to artificia1 respiration when it is needed. In any case, the circuIation shouId constantIy be watched. The diffIcuIties of resuscitation are enormousIy increased by circuIatory faiIure and the patient wiI1 sureIy die if the heart absoIuteIy stops for more than seven minutes. An earIy resort to intravascuIar infusion with epinephrinized saIine insures against cardiac arrest, and an intravenous outfit shouId aIways be ready for instant use in every operating room. The smaIIest quantity of epinephrine soIution that wiI1 produce the desired effect (it may be x minim, it may be IOO minims of the I : IOOO solution) shouId be used. We start with 200 C.C. of saIine soIution containing IO minims of the standard I : IOOO epinephrine soIution. The instant the puIse responds, even though but a smaI1 fraction of the epinephrine has entered the vein, the flow is arrested to be resumed intermittentIy Iater as required. In this
.
NEW
SERIES VOL. XVII, No.
Babcock-ArtificiaI
2
way a prolonged effect may be produced. If there is no response the percentage of epinephrine in the saline is very rapidly increased unti1 a response is evoked. An excess of epinephrine is harmful, putting at times an enormous strain upon the heart and vesseIs and being foIlowed by corresponding secondary circulatory depression. With absolute arrest of the heart, a direct IocaI stimuIus is usualIy necessary to carry the epinephrine into coronaries where *it becomes effective. With the open abdomen subdiaphragmatic cardiac massage is easiIy produced. The operator shouId be carefu1 not to have the Ieft Iobe of the liver interposed between the interna hand and the diaphragm. In about 20 cases of cardiac massage the subdiaphragmatic method was the only one that gave me an enduring effect. OccasionaIIy, I have found it wiI[ fair where a transthoracic massage wiI1 stimulate the heart to action. It is not necessary to turn back a flap of the chest waI1 for transthoracic cardiac massage. A stab is made through the Ieft third interspace 2 cm. from the sternum (to avoid the internal mammary artery) the finger introduced into the chest as the knife is withdrawn and curIed about the Ieft border of the heart, which is rhythmicaI1.y compressed against the overly&g chest La11 by flexing the finger. The intraventricurar iniection of eDinephrine gives a vioIent stimuIus to t’he heart that is very effective and has IargeIy dispraced cardiac massage. A 22 gauge needle 9 cm. Iong is entered at the Ieft I
433
Respiration
American Journal of Surger)
225
border of the sternum in the third interspace, carried in and mesiaIIy unti1 the resistance of the venticuIar waII is past, aspirated to prove that the point of the needIe is in the free ventricurar cavity and the withdrawn bIood reinjected with the 3 or IO minims of epinephrine in the Luer syringe. These drastic procedures should rarely be necessary. During the period of dire emergency the subcutaneous injection of stimurants may divert the attendants from quicker and more effective measures. Therefore, we avoid them. FinaIIy it may be noted, that the need of an intracardiac injection during an operation usuaIIy indicates that the patient has not been watched with sufficient care, or that the proper prophyIactic measures were not instituted suffIcientIy earI?. SUMMARY I. The conventiona methods of artificia1 respiration are not we11 adapted to operating room practice. 2. The operator shouId use no method of artificia1 respiration that does not cause adequate quantities of air to enter and Ieave the patient’s chest. Artificial respiration is not a gesture, it is an effect. 3. Efforts at artificial respiration shouId be continued if necessary for man,y hours, or at Ieast unti1 the heart no Ionger responds to even the most powerful direct stimulus. The patient shouId be kept warm. 4. A time tested and effective pIan for routine use is here given.