ogist. But what do the internist and the gastroenterologist know of the new physiology created by the operative procedures? Yes, they admit perhaps that medical treatment must follow each and every surgical intervention, but what kind of medical treatment? Naturally this treatment cannot be the same as that which was used before the operation, because the anatomical relations, shape, size, and function of the digestive organs have changed, and, therefore, the treatment must conform itself to the new conditions created by the operation. Who is competent to judge of all these elements? Obviously not the surgeon, who is not interested in the medical treatment, not the gastroenterologist, who cannot know what changes have taken place. It is evident, therefore, that the real gastroenterologist who wants to undertake the treatment of cases suffering from ulcer of the stomach and duodenum must be

FIG. 5.-Case IV. Showing apparent adhesion in the cecal region that did not exist.

the same man who makes the diagnosis, applies the medical or surgical treatment required in each case, according to the patient's age, sex, and physical, mental, and social condition; the location and duration of the ulcer, and certainty or uncertainty of diagnosis. And when this complete gastroenterologist has been developed, we shall not hear any useless discussion on the antagonistic value of internal and surgical treatment, and have the gastroenterologist point out the mistakes made by the surgeon, and vice versa, because valuable time will not be wasted by the real gastroenterologist with stomach tubes and buckets, when the patient has a chronic indurated ulcer, and we shall not see young boys and, girls especially, operated on for duodenal ulcers due to anemic conditions, which can be cured in the greatest majority of cases by proper internal treatment better than by any surgical procedure.

Actual personal experience at the operative table will teach the gastroenterologist many valuable lessons; and we believe that the gastroenterologist of the future must be a competent diagnostician who can judge of the value of each diagnostic means, such as history, physical examination, gastric analysis, and roentgen rays and know how to apply it to each individual case; must have had actual personal experience in applying the rational and complete medical and surgical treatment appropriate to each case; must be able to improve his diagnostic ability by actual visualization of conditions at operation; must follow his cases, and so profit by his own mistakes, which are the only ones that leave a deep impression and teach a valuable lesson.

ROCHESTER, MINN.

CHIEF OF SECTION ON DERMATOLOGY AND SYPHILOLOGY, MAYO CLINIC.

SO-CALLED intramuscular injection is a procedure technical acquaintance with which is generally taken for granted in therapeutic instructions so that a rehearsal of the steps of the procedure seems correspondingly uncalled for. Observations extending over several years have led me to suspect, however, that this method of administering medication in general, and mercurial preparations in particular, involves certain principles and a degree of manual dexterity for its accomplishment secundum artem with which physicians are often unfamiliar. A folder recently issued by a pharmaceutical concern, purporting to describe a satisfactory technic for the intramuscular injection of one of its preparations, seems, at least so far as its illustrations go, to violate the first principles of intramuscular technic. For these reasons the following description of a mode of procedure which has proved serviceable in about 40,000 injections is offered.

My experience with the injection of large quantities of solutions (100 c.c. or more) into the buttocks directed my attention to a phenomenon which suggested that the contents of the so-called intramuscular injection when properly introduced are deposited not within the body of the gluteus maximus or between its fasciculi nor yet within the subcutaneous fat, but in the areolar tissue on the upper surface of the fascia forming the extension of the fascia lata covering the gluteus maximus. A large quantity of fluid when thus injected, instead of forming a tense induration in the body of the muscle or spreading laterally onto the hip and thigh or appearing at the sacral margin, presents promptly at the lower border of the buttock in the gluteal sulcus. The markedly better absorption thus obtained and the freedom from local irritation even on the injection of a highly irritating drug were demonstrated by the work of Wechselmann and Eiche* who advocated this technic for the comparatively painless and uncomplicated administration of arsphenamine intramuscularly. A similar principle may be employed

*Wechselmann and Eicke: Zur Technik und Wirkung subkutaner Neosalvarseninjektionen. Münch. med. Wchnschr., 1914, lxi, 535-538.

in the administration of the mercurial preparations into the tissue of the buttock with equally satisfactory results. The technical detail necessary to achieve this end, and the avoidance of other familiar complications of intramuscular injection such as

FIG. 1.-Prone position for intramuscular injection, showing arms hanging over the sides of the table to promote relaxation.

deep and superficial infiltrations, embolism, necrosis, and abscess formation, may be briefly described as follows:

1. The Position of the Patient.-Injections into the buttock are given to best advantage with the patient lying prone on a table. Other positions induce tenseness of the tissues, which favors leakage of the injected substance along the needle track, makes a careful estimation of the depth of tissue and the placing of the needle difficult, and also makes it difficult to avoid mechanical awkwardness in carrying out the procedure.

over the side of the table (Fig. 1). His legs should be placed in a position of moderate internal rotation "toed in" (Fig. 2a). The difference in the appearance of the buttock when the patient attempts to keep the heels together is well shown in Figure 2. Dimpling of the lower outer quadrant of the buttock as shown in (b) disturbs the anatomical relations, is a sign of incomplete relaxation, and is the position ordinarily assumed by every patient who fears the introduction of the needle.

2. Instruments.-The 2 c.c. glass Luer syringe and three lengths of needles, one for very thin or flabby buttocks; one for medium, and one for fat buttocks are necessary. The aspiration technic described herewith for detecting the presence of a needle in a vein makes possible the use of a smaller gauge needle than that required when the venous pressure alone is depended on to yield a flow of blood from a misplaced needle. My preference is for 22 gauge needles 1.5 inches, 2 inches, and 2.5 inches from the tip of the hub to the point (Fig. 3).

3. Point of Injection.-Injections into the buttock should, in general, be given into the upper outer quadrant near its inner angle, approximately at the point indicated by a dot in Figure 4. If the injection is given into the upper part of the outer quad

FIG. 2. a. "Toed in" to show the relaxation of the buttock.

FIG. 3. All glass Luer syringe with the various sizes of needles used for intramuscular injection.

rant or into the inner quadrant near the sacrum, even a short needle is likely to strike bone, or the injection of the irritant substance above the periosteum or about the roots of the sacral plexus will give rise to induration and pain, and may, as Neisser points out, induce an obstinate sciatica. Injections given into either of the lower quadrants are subject to pressure on sitting, and are correspondingly painful. If administered near the great sciatic nerve a neuritis may result. Such injections, moreover, cannot be deposited on the fascia with the exactitude possible in the upper outer quadrant, and for this reason are likely to give rise either to superficial nodule formation, abscesses, or deep firm indurations.

4. Technic of Injection.-The syringe and needle may be sterilized with alcohol. The alcohol should be thoroughly expelled from the syringe and the needle wiped with sterile cotton moistened with al

a tense musculature.

Relaxation after the patient assumes the prone position should be complete. Attention to certain details assists in securing a satisfactory cooperation on this point. The patient should drop his arms

syringe through the needle which has been previously attached, and the needle is again wiped. The syringe is grasped in the right hand (Fig. 5). The left hand is placed flat on the buttock and with moderate pressure is drawn firmly downward toward the

patient's heel, thus flattening and fixing the tissues (Fig. 6). The syringe is introduced to its full length by a quick stroke at an angle of approximately twenty degrees from the vertical in a sagittal plane, with a slight inclination inward (Fig. 7).

needle in the expectation that the pressure of the blood in a capillary vessel will cause a backflow of emulsion or of blood, as the case may be. I have never seen an accident of any type occur if the aspiration step in the technic was rigidly adhered to. As soon as it appears that nothing can be aspirated from the deep tissue about the needle point, the contents of the syringe may be injected (Fig. 9), the right hand maintaining the proper angle of the needle.

It is not necessary in this technic to use a sign, such as Wechselmann's torsion sign, for demonstrating that the needle point is near or on the fascia. The site of the injection, the length of the needle when properly adapted to the type of buttock, the fixation of the tissue with the left hand, and the position of the syringe when introduced soon become matters of habit and seem to place the injected material in such a way that induration is a very unusual occurrence. The flow of injected material into

FIG. 4.-Outline of the buttock and pelvic bones illustrating (black dot) the point in the upper outer quadrant, about which injections may be made to the best advantage.

The removal of the left hand slightly increases the slant of the syringe. During the process of introducing the needle the piston must be controlled by the pressure of the index finger against it above the barrel, to prevent the leaking of a solution or thin emulsion.

5. Testing for the Presence of the Needle in a Blood Vessel.-As soon as the needle is introduced the syringe is steadied with the left hand while an attempt is made to aspirate by pulling upward on the piston with the right hand (Fig. 8). This at

FIG. 5.-Right hand holding the syringe. tempt should be continued for at least ten seconds. This in my experience is an entirely safe and much more trustworthy method of detecting puncture of a deep vein or capillary than is the mere detaching of the syringe or the introduction of an empty

FIG. 6.-Left hand drawing down the buttock.

the tissue should be free and the needle point should not "feel" as if stuck in a board. A little experience soon enables one to control the technic by recognizing the deep, painful lemon or orange sized induration that has followed on too deep injection (intramuscular) and the hazel-nut to hickory-nut sized nodule in the skin or panniculus secondary to too superficial injection or to leakage along the needle track.

Deposition of injected material along the needle track is avoided: first, by securing complete relaxation; second, by using a small caliber needle; third, by completely emptying the syringe before withdrawal; fourth, by a rapid withdrawal; fifth, by quickly pushing the tissues which have been drawn downward by the left hand back to their normal position like a sliding valve the moment the needle is withdrawn; and sixth, by light massage with a cotton pledget over the site of puncture which results in a rapid flattening out of the injection mass in the

areolar tissues over the fascia (Fig. 10). In buttocks which have been rendered fibrous by repeated courses of intramuscular injections, leakage cannot be prevented, and the intramuscular injections must ultimately be abandoned.

Attention to several additional details materially contributes to a uniformly satisfactory technic. It goes without saying that the buttocks should be used in alternation for injection. Needle points should be of a rather long bevel and exceedingly sharp. The use of a needle with a turned point is very painful. In wiping the needle a turned point can be detected by a grating sound and feel as it passes over the cotton, often when it is scarcely visible. The operator may unconsciously turn the point of his needle by touching it against the bottom of his bottle of emulsion or solution when filling the syringe. For this reason every movement of the needle should be carefully controlled and it should never be brought into contact with hard substances. A needle which

FIG. 7.-Introduction of the syringe. has been allowed to become rusty, corroded, or pitted will also bring a protest from the patient.

The breaking of a needle is one of the most unpleasant complications of intramuscular injection and may be due first, to an incorrectly placed puncture which causes the needle to strike on bone, fracturing it at some point along the shaft; second, to a sudden movement on the part of the patient, especially if the point is caught in the fascia or lies in the muscle, and third, to weakening of the needle by internal or external corrosion. The first cause seldom operates except as a result of gross misjudgement. The second can usually be avoided by an effort to secure the cooperation of the patient and by guarding against sudden movement in those in whom cooperation cannot be expected (children for example). The third cause can be controlled by frequent inspection of needles with a forcible attempt to bend the shaft on the hub. If a steel needle is used for corrosive solutions, its life will be short and inspection must be frequent and critical.

FIG. 9.-Injection; the emulsion or solution should flow in freely and not have to be forced.

operator keeps his presence of mind. On the other hand, the moment the left hand is released from the buttock the needle is lost and can usually only be identified by the roentgen ray and removed through an extensive surgical incision. Such situations are

so embarrassing that the finest types of steel and tempered gold needles should be used for intramuscular work.

In the use of insoluble suspensions for intramuscular injection a word of caution as to the preparation of the suspension is important. Concentrated suspensions requiring small amounts for each injection are often less painful than thin suspensions. An insoluble preparation made up in a fluid base, settles rapidly and the collected powder can only be returned to suspension by from five to twenty minutes persistent vigorous shaking, and kept in suspension by shaking after each injection. The suspension may appear entirely homogeneous when a considerable portion of the solid material still adheres to the bottom of the bottle. A satisfactory test of complete suspension consists of shaking until none of the suspension can be recognized in the groove at the juncture of the sides and bottom of the bottle when the bottle is inverted.

FIG. 10. On release of the left hand the tissues of the buttock return to their normal position, producing a valve action. The emulsion is spread out in the epifascial tissue and leakage prevented by massage with a cotton pledget.

6. Treatment of Complications.-If blood is obtained on aspiration after the introduction of the syringe, even in the minutest amount, the syringe should be withdrawn and the procedure repeated 1 cm. or more from the site of the unsuccessful attempt. To continue the injection in the face of a return of blood or even a tinged suspension may be attended by fatal consequences from embolism.

Superficial indurations or nodules may be treated by painting them once or twice a week with iodine and requesting the patient to pinch and massage them between the thumb and forefinger. Deep indurations attended with pain from injection below the fascia are much relieved by prolonged hot applications and massage. Indurations seem to occur with special frequency in certain subjects, especially the obese, and are sometimes unavoidable even with the best technic. Each node represents a certain amount of encapsulated mercury which may be

abruptly released for absorption by trifling trauma such as that of sitting down more heavily than usually. The sudden onset of salivation in patients who have not had intramuscular injections of insoluble mercurial salts for a considerable period may be to some extent a result of technical errors which have interfered with absorption. There can be no object in continuing a method of administration in which persistent nodule formation, even with a careful technic, shows that the drug does not absorb.

Pain referred down the leg has always in my experience been evidence of the technical error of injecting too deep or too near the sacral plexus and the great sciatic nerve.

Pulmonary embolism following the use of insoluble salts, such as mercury salicylate, calomel, and gray oil, probably cannot be absolutely avoided but should be an excessively rare occurrence. The symptoms of pulmonary embolism may vary from a slight and transient cough after the patient rises from the table to evidences of extensive pulmonary infraction with severe and persistent cough, rise of temperature, pleural irritation, and occasional pneumonic complications. Pulmonary embolism may occasionally supervene some hours after an injection made in accordance with the strictest technical exactness. Cerebral embolism is exceedingly rare.

Abscess formation I have seen only twice in 40,000 injections. The abscess is usually sterile and resolves promptly on evacuation. A certain percentage of deep indurations doubtless undergo central softening, but under rest and hot dressings the process subsides.

BACKACHE.

A CONSIDERATION OF LOW BACK PAIN OF A MILD TYPE.* BY SIGMUND EPSTEIN, M.D.,

NEW YORK.

ORTHOPEDIC CHIEF, MOUNT SINAI DISPENSARY AND BRONX HOSPITAL.

use.

FORTY years ago the plaster-of-paris jacket treatment of spinal diseases and deformities had been firmly established by the late Lewis A. Sayre. The jacket has since received much criticism; it remains to-day, however, the sheet-anchor for spinal injuries and inflammations. Still there exists in many minds the fear that patients and their doctors express, "that they are heavy, and they interfere with breathing." This can be answered in a satisfactory manner. We have learned to avoid many mistakes of commission and omission in their application, as well as in the selection of suitable cases for their The plaster room is one of the busiest spots in any orthopedic dispensary or clinic. We have learned to instruct parents or attendants in the art of keeping the skin clean and free from accidentally dropped crumbs, coins, keys, etc.; the use of suitable felt for padding, over spinous processes or bony points is a small detail carefully watched over by trained attendants, so that we are no longer surprised to see instances, where the appliance has been worn for one or two years, with entire comfort. With experience has come better judgment in the removal of jackets at the proper time, to be replaced by light braces. The use of such adjuncts as the jurymast and the shoulder straps, and the in

*Paper read before the New York Physicians' Association, November 23, 1920.