tonitis not due to perforated lesion. There seems to be doubt in a good many observers mind, as to whether any good is done by surgical interferences indeed, if one believes that drainage is impossible and the fluid thrown out not is really harmful, it is difficult to see what good the surgeon can do.

Dr. C. Wallace, of London, makes these remarks in the British Medical Journal of 1907, "Drainage of the abdominal cavity, in cases of peritonitis, is suppose to serve two primary purposes: (1) The removal of noxious products; (2) the relief of tension. Although most universally practised, it is doubtless how far it really performs these duties. Some years ago I expressed the belief that the proceding was necessary as far as the peritoneal infection was concerned and very harmful to the abdominal wall."

The principle of abdominal drainage at the most dependent portion is so firmly established that to enunciate it seems to be folly.

I am of the opinion, however, that surgeons will continue to try to drain the peritoneal cavity or intraperioneal abscess, but it is also possible that the day may come, when drainage of the cavity will no longer be thought of.

According to Yates, experiments on dogs he found that his abdominal drain was completely shut off from the general peritoneal cavity in less than ten hours.

And E. F. Murphy, about this time with his experiments on cats, found that his rubber tissue wick drained up to fifty-two hours. So we see by these experiments how quickly the peritoneum with its plastic exudates is prone to wall off the exit of fluid in the cavity.

Some claim that intra-abdominal pressure favors the attempt to drain. In ordinary health it is doubtful if there is such a thing as intra-abdominal tension.

It is by no means uncommon when opening the abdomen, to find difficulty in raising the peritoneum, from the underlying intestines, until the air has been admitted, when the peritoneum at once rises.

It is quite possible that the tension of the peritoneum in peritonitis is an attempt to save the intestines from pressure, by drawing a tight cord as it were from the costal margin to the pelvic brim.

In any case it is difficult to see how a simple incision in the muscles, can have much effect on the tenseness of the abdomen; indeed, it does not as any one can see for himself, for the abdomen remains tense, even after the infliction of a long wound.

Again if there was a marked fall of pressure, followed by an incision the effect on the circulation would be disastrous, but the blood pressure does not fall when the abdomen is opened.

The two important factors, common in all modern treatment of perforated peritonitis are early operation and removal of the infecting cause. Of course the sites for operation by the transperitoneal route from which subsequent leakage may be feared, such as injuries of the rectum, ureters or bladder, pancreas, gall-bladder and duct, should be drained.

And also a local peritoneal abscess should be treated as any other abscess in the body by a drain. But drainage of the peritoneal cavity is altogether another thing for the peritoneum cannot be considered as a simple abscess cavity, for the reason that it is full of viscera, which limits the movement of fluid.

This is well seen in the formation of secondary abscesses, even after drainage has been employed. On the other hand, it has been proven by the experiments of Dr. Wm. Coughlin, that the Fowler's position does very little good, for he states that with the body supine, the lowest point in the pelvic cavity is about six inches lower than the upper margin of the symphysis pubis, while with the body vertical (standing or sitting) the lowest point in the pelvic peritoneal cavity is two and a half inches below the upper margin of the symphysis pubis.

Dr. Coffey showed that in order to have fluid flow into the pelvis from the hollow of either side of the spine without turning the body on the side, it was necessary to raise the thorax and upper abdomen, so that the long axis of the abdominal cavity was on an angle of 60 to 70 degrees with the hori

zon.

I

Let me quote again from J. W. Kennedy, who says, we do not believe in the gravitation of infectious fluids through inflammatory barriers produced by adhesions. The great number of secondary abscesses, which have been accumulations between the adherent viscera necessitating secondary operations are proof that the infectious fluids did not gravitate to the pelvis while the patient was in the Fowler position. have seen a number of these sleepless and fatigued patients taken out of the Fowler position, turned over on the right side, with thighs flexed, and then go fast asleep for eight to ten hours. Fatigue must be relieved early or we lose these patients. the drainage from the most dependent point means so much to the advocates of the Fowler position, you will find the incision

If

in the right groin with the patient turned well over on the right side, with the relaxation of the abdominal muscles incident to the flexed thighs, gives you about the same point of drainage, and is the child's natural position of flexion and rest."

It has been stated that Dawbarn poured milk into the peritoneal cavity of a cadaver and was unable even to wash it all out, though he repeatedly flushed the cavity with water.

Helvetas, Mikulicz and Delbet poured water into the cavity and never could get it all back. Helvetas, so Sanger reports, allowed 500 gms. of water to be poured into the abdomen, then tubes were inserted and some knocks were given with the hands and to Helvetas' surprise no fluid came out.

Can you tell me how many cases of peritonitis, due to operative infection recover? Very few indeed, and under such conditions the surgeon is well nigh helpless. Why? Because there is no lesion giving rise to the infection that we can remove. I would submit that with the removal of the infecting source and the closure of the abdomen, the surgeon's work is over.

In conclusion, I wish to state, in view of the fact of the perfect technic of modern surgery in regard to the closure of abdominal incisions, therefore lessening the liberality of hernia to a minim. A large enough incision to admit the hand in a great majority of cases is due the patient, in order to fulfil our obligations and bring about the best surgical work.

Also in light of recent experiments it is shown that the pelvic cavity is not completely drained of water, although the body be placed (bolt upright) to 90 degrees and that the abdominal cavity is not a drainable cavity, for the reason of the short space of time it takes for the drain to be walled off by the peritoneum and plastic exudate, hence shutting off your communication with the cavity.

The Fowler's position does not drain the lowest point of the cavity and is detrimental to a weak heart, uncomfortable to the patient and against low blood pressure.

The abdomen should be drained when there is a probability of a leak; but on the other hand, the surgeon's work is done when he removes the infecting sources and closes the abdomen.

Under "Surgical Consideration" in the American Practice of Surgery, Vol. II, page 116, we find these words: "The objections to drainage of the abdominal cavity are manifold: The drain keeps the wound open and delays union and the tract occupied by the drain soon becomes infected, and there

by adds a dangerous satrium for the entrance of bacteria into the peritoneal cavity. A drain is always an irritating body, interfering with the natural resistance of the peritoneum and increasing the serous flow in proportion to the extent of wounded and serous surfaces exposed to its irritating

contact.

The drain often fails to remove fluids, for becoming quickly clogged, it may act as a plug and stop the drainage. The removal of the gauze drain is extremely painful, and besides it may break down granulations and protective adhesions, thus increasing the risk of infection or causing prolapse of the omentum or intestines and possibly inducing hemorrghage.

Drainage predisposes to hernia, which is found in 80 per cent of the cases; and postoperative ileus is oftener encountered in drained than undrained cases.

Drainage requires frequent changes of dressings. Again, the great objection to pertioneal drainage is that it does not usually accomplish its purpose, for the mechanical difficulties prevent this after a short time. All drains become walled off from the general cavity in a few hours, and their functions then cease.

Tubes cease to drain in about twelve hours, and in twenty-four hours the meshes of gauze fill up, the drain becomes adherent to the peritoneum and its capillarity is lost."

520 State Bank Building.

THE TECHNIQUE AND DIFFICULTIES OF INTRAVENOUS MEDICATION.

E. H. MARTIN, M. D., Hot Springs, Ark.

Before the introduction of salvarasn into. general use general use intravenous medication was confined to the administration of saline solution in cases of shock requiring more im. mediate results than could be expected from hypodermoclysis. This was practically our only need for this method except in a few instances when such drugs as bichloride of mercury or quinine were administered and these were given in such small bulk that only a large hypodermic syringe was required and the vein was penetrated directly through the skin. This was not difficult as a very fine needle could be used.

But for the administration of saline solution by the pint the very fine hypodermic needle would not do and it became the cus tom to cut down on the vein and give the saline through a canula. This method was not too much trouble when only called into

But

use in emergency and to save life. when it came to giving repeated doses of salvarsan to the same patient it was not justifiable to destroy veins by cutting them, and it was also too much trouble. I cannot speak too strongly against the reprehensible practice of cutting down on a vein for this purpose. An unnecessary wound is made and sutures are required, leaking into the tissues is quite usual when the vein has been exposed as the vein lacks support and will not close well around the needle unless a ligature is thrown round it. Not only does cutting down on a vein give more trouble, but it also renders infection possible. But the most serious objection to cutting is the tell tale scar. Ladies with such a scar on each arm are marked for life as syphilitics or ex-syphilitics, while in fact the intravenous medication may have been for other cause. These objections led to the adoption of direct intravenous penetration and the method usually adopted has been to stab through the skin and upper wall of the vein at one effort. There are several objections to this, but the one most important is that if the needle be sharp enough to use readily, it may penetrate the lower wall of the vein also, and if dull or blunt, or stub pointed much force is necessary, undue pain is inflicted and the vein frequently missed entirely or torn.

As salvarsan is more frequently used by this method than any other drug I will give you my technique for mixing and administering same.

I use the Boehm double gravity apparatus with the two-way stop cock, but have modified it by adding an eight-inch extension where the needle was intended to fit the outlet of the stop cock. This extension consists of two pieces of rubber tubing each three inches in length joined by a window of glass tubing two inches long. I use a needle made without any chamber, but with a straight lumen from point to butt, and the butt is swelled to fit the rubber tube of the extension. This needle is very sharp and has a long bevel, it is made in three sizes, designated as four-minute, six minute and eight-minute sizes, according to the time needed to deliver 250 c.c. at ordinary pressure. The eight-minute needle is only used for very small veins, and in a majority of cases the four-minute needle is preferable.

The entire apparatus, including yoke of cross piece of stand is put in the sterilizer and boiled. Four-tenth of 1 per cent salt solution is prepared with distilled water and this is put in quart bottles, and is set in the sterilizer and also reboiled. The ampule of

salvarsan with its file is dropped into alcohol. The mixing table is drawn up about eighteen inches from the operating table.

This small table is then covered with sterile towels after the operator's hand have been made surgically clean. An assistant places the non-sterile stand on one corner of this table. The operator then removes the apparatus from the sterilizer, part by part, and puts it together. This being done, the mixing cylinder, is removed from the sterilizer and filled half full of sterile salt solution. The dose of salvarsan is removed from the alcohol and filed open and contents carefully dropped into the mixing cylinder. A few shakes gives a perfect solution. An assistant then drops the 15 per cent hydroxide of soda solution into the mixing cylinder and the usual precipitation occurs, but the alkaline solution is generally accomplished with about twelve to fourteen drops of the hydroxide solution. When neo-salvarsan is used the salt solution is not needed. Both of the cylinders of the intravenous apparatus are then filled half full of the salt solution and enough of this is permitted to flow from the left-hand cylinder to eliminate air bubbles. The switch is then turned to the tube leading from the right hand cylinder, and it is emptied down to the narrow neck, leaving the salt solution just showing above the rubber tubing. Enough salt solution is added to the mixing cylinder to make from 250 to 300 cc. and this solution is then inspected for floating particles, and it is then strained through sterile gauze into the right hand cylinder of the apparatus. This solution will probably cool to about the right temperature while the patient's arm is being scrubbed, which is done after the patient is on the table, and when everything is in readiness an assistant places the tourniquet around the arm as high as the rolled up sleeve will permit.

An arm rest made of enamelled sheet steel, eight inches wide and twenty-four inches long, not counting a turn down of three inches to give elevation to the distal end, is placed so as to have the low end on the operating table under the patient's shoulder and the high end on the mixing table. The arm rest is covered with clean towels.

After the veins are distended the arm is placed upon the arm rest and the operator gets his sterile needle from the sterilizer, his hands, of course, still being surgically clean. The assistant then turns the stopcock each way, making a last inspection for air bubbles, and finally turns on the salt solution, leaving it turned on at the stop

cock and controlling the flow by pressing the rubber tubing of the extension between the thumb and finger, being very careful not to get within two inches of the end of the rubber tube, as the assistant's hands are not supposed to be clean. The operator, being comfortably seated, introduces the very sharp needle detached. It is better to introduce it through the skin alongside the vein, and not try to enter the vein while going through the skin. With the utmost deliberation the point is now turned slightly toward the vein and pressure gradually increases until the needle enters the side wall. Nine times out of ten it will enter without a tear and there will be no leak around the needle. If the vein is very large, it is better to enter at a greater angle, as it is the large vein that gives a little tear and causes about the only trouble which ever occurs when using this technique.

As soon as the needle enters the vein the

blood will spurt through it and at the sight of this the asssitant, who is still holding the rubber tube compressed in his left hand, detaches the tourniquet with his right hand and almost at the same moment passes the rubber tube in his left hand to the operator who adjusts it over the butt of the needle. With the needle full of blood and the tube full of salt solution, there is no possibility of air bubbles, and with the needle having no chamber, there is very small chance of a clot forming or the needle becoming stopped up. As soon as it is apparent that the salt solution is flowing intravenously without trouble the salvarsan is turned on, and after the salvarsan has been given the vein is washed with the salt solution in the usual manner. When the needle.is removed the patient should hold the arm perpendicularly for

half a minute, and as soon as it has been cleansed with a wet sterile towel, a small spot of collodion will close the needle hole in the skin perfectly. The opening in the vein being from one-fourth to one-half an inch from that in the skin, the tissues close the former without trouble. The technique is thus very simple, but like all simple things it must be followed carefully and skillfully to avoid possible difficulties.

Some of these are as follows:

1. Vein tearing.

2. Penetrating both walls.

3. Clogging of the needle.

4. Invisible vein.

5. Vein too movable.

6. Results from old distilled water.

7. Results from too rapid flow.

8. Results where patient's lungs are insufficient or abnormal.

9. Angio-neurotic edema.

I have not mentioned air bubbles or chances of direct infection with living organisms, as both are entirely avoidable and quite inexcusable.

Vein tearing is an accident accident usually caused by trying to introduce the needle into the vein at too small an angle, or by using a dull needle. If the needle at first fails to engage the wall of the vein it may scratch a larger hole in the vein than the needle can fill, the result is a leak and a puff in the tissues, a signal to remove the rubber tube from the needle and to replace the tourniquet. If you then get a good flow of blood through the needle and can maintain this while pushing the needle further up in the lumen of the vein you may be able to continue without increasing the leak but usually you cannot do this.

If both walls of the vein are penetrated it is at times possible to rectify the trouble by slowly withdrawing the needle and pushing it further up into the lumen of the vein, this may fail.

If failing in either case the best method is to leave the needle in situ and make another "stick" with another needle, several of which should be ready in the sterilizer. Should you remove the needle which has failed you will have a small hemorrhage into the tissues when the tourniquet is reapplied, leave it hanging until through. If you cannot make another successful stick in that arm remove your needles and close the needle holes with collodion, turn the operating table and wash up the other arm.

Clogging of the needle and a consequent slow flow or stoppage of the flow rarely occurs with the needle I use as it has no But at

chamber for the blood to clot in. rare intervals it will happen that a particle of fat may get into the lumen at the point and clog the needle. When this occurs do not try to clean your needle with the wire Leave as an embolus might be caused. your needle in situ and use another needle higher up.

Invisible veins in a fat subject cause difficulty only to a beginner who will soon

learn that this is the easiest "stick" of all. If the vein can be palpated, no matter how deep, one has only to proceed as if he sees it and he can readily introduce the needle by the sense of touch alone. Such a vein is not movable, but is as safely held by the fat as a specimen imbedded in parafin for the microtome. The vein can not move so the stick" is easy.

The contrary is the case in a thin sub.

ject with no fat and a small movable vein which runs around under the skin like a fishing worm. Here is where the stick looks easiest but is most difficult. Nothing but practice will enable you to negotiate such a vein successfully. The beginner will nearly always go through both walls.

The water used for intravenous medication should always be distilled the day it is used. After the salt has been added to it or even after it has been poured into clean bottles it should be resterilized. If the distilled water stands a few days organisms will be found growing in it. This may be a fungus like organism, but any of the saprophitic germs will at times be found and the result to the patient will be practically the same, no matter what organism has chosen to grow in the distilled water. If the water is very old the results of plant life will show in it sufficiently to cause even a careless operator to filter the water before using it. If filtered, the organism itself is removed but it leaves the water a solution of toxins which have been generated by such colonies. There is no way to remove the toxins from distilled water except by re-distillation. Neither boiling nor filtering can affect toxins. When a solution made of old distilled water is administered intravenously the toxins that are thus injected will cause a reaction very promptly. Sometimes such a patient will have a chill before he reaches his room. This paroxysm from a toxin that is injected with the medicine will never be slower in coming on than twenty or twenty-five minutes while the reaction caused by a toxin generated in the patient's system by the killing of organisms will be an hour and a half or two hours in coming on. A great many physicians through the country are using old distilled water, and some are even using ordinary tap water. Of the two it would be better for the patient to use deep well water freshly drawn which has not had time to become the home of any saprophitic germs, than to use the old distilled water. The chemical substances contained in deep well water would probably not interfere with the solution of the remedy to be used. and after it had been properly sterilized it would be safer than the old water that had been distilled even.

A too rapid flow into a vein may cause a slight quickened breathing on the part of the patient and a feeling of oppression. This is due to the fact that in diluting the blood in the right heart to too great an extent the fluid pumped through the lungs is largely the fluid being administered and as it has no oxygen carrying power the pa

A man

tient suffers a slight dyspnea. weighing over 180 pounds can take 250 cc. into his circulation in four minutes without feeling at all different but if the same amount is given to a small patient weighing 100 pounds or less and having only about half as much blood as the large patient, six or eight minutes should be taken to administer the dose. When the patient's lungs are insufficient or abnormal the solution being introduced into the veins and carried through the lungs will frequently cause a temporary irritation. I have seen this in patients with only partial lung capacity. One patient especially with one permanently collapsed lung and several others who were suffering from bronchitis have been inclined to cough slightly during the intravenous administration. This can, in the former case, be remedied by lowering your apparatus and slowing up the administration, but where the lung is inflamed or bronchitis exists it is better to get through with the operation as quickly as possible.

The

In one case intense nervousness and fear and also an over-loaded stomach in a patient after a recent attack of indigestion seemed to cause an attack of angio-neurotic edema during the administration. others, three in number, have also occurred while the patient was on the table. One of these was quite severe and the patient's eyes were closed by the swelling of the lids. In fact her entire face looked as if many bees had stung her. The only precaution we can take to avoid such an unpleasant occurrence-for it is decidedly unpleasant though harmless in the end-is to refuse to administer an intravenous dose of any thing to a patient who is manifestly frightened or who has just eaten a large meal. The fact that the angio-neurotic edema does not seem to ever occur with the first dose would suggest anaphylaxis, but I feel certain, on the contrary, that the nervous condition of the patient is entirely responsible, though a full stomach is also a predisposing cause.

I can think of no other difficulties which may occur in a carefully carried out intravenous administration and those that I have mentioned are certainly not of great consqeuence.

One rule should be adopted by any one doing intravenous work and that is to remember always to be just as careful in every particular in giving your thousandth dose as you were in giving the first.

DISCUSSION.

DR. R. L. SUTTON: Several years ago, before the discovery of salvarsan, we had an effi