effectually taken care of the remaining micro-organisms in the areas that the tube could not possibly have drained. Let us assume that we have a case of peritonitis caused by a ruptured gastric or duodenal ulcer, we operate, insert a tube, and make use of Fower's position. What do we expect will become of the remaining products of the induced inflammation? Do they gravitate to the pelvic region and escape through the tube, or does the peritoneum successfully dispose of them? We must remember that the pelvis is not a perfect funnel, but is somewhat like a saddle, the pommel being represented by the uterus or bladder with a depression on each side. Then how can all the fluid escape? What then becomes of the remaining part?

Again, in perforative appendicitis, where no protective barrier to the spreading of the inflammation, or to the escape of the contents of the appendix, has been formed, what becomes of the pus that is widespread throughout the peritoneal cavity, or of a stercolith that may have escaped detection, when drainage alone has been relied upon? All these products are not carried away by the drainage tube, and cannot be from the form of the pelvis. It is only the excess that escapes, and for a very few hours at best, the limit being probably forty-eight hours, as the tube becomes thus rapidly encapsuled by fibrous tissue, leaving a sinus, from which alone infective fluid is discharged, and not from the surrounding inflamed peritoneum, as by this time a probe cannot be passed beyond the cylindrical wall of this sinus, unless sufficient force is exerted, when it will penetrate the newly-formed tissue. In the cases of recovery, where drainage was made use of, after the tube had become encapsuled, the remaining areas of the similarly infected peritoneum must necessarily have effectually disposed of the products of inflammation. Thus we have an army of phagocytes poured into the field to give fight to the invading and rapidly multiplying army of bacteria. The former won the day because the bactericidal action of the phagocytes was greater than the virulence of the micro-organisms, after their balance of power, the numbers that escaped up to the time of encapsulation of the tube, had been removed. Now, does it not seem reasonable to assume that this great serous sac is all the more capable of successfully coping with the small amount of infection that remains when free flushing is made use of until the return flow is clear, after closing without a drain, when no necrotic tissue exists and when sutured parts are secure, especially if this remaining infection be diluted by leaving within the abdomen a large amount of normal saline, and the patient placed in Fowler's position? Is it not more probable that

a much greater quantity of infective buid can be evacuated from the peritoneal cavity by freely flushing through a liberal incision or incisions, than can possibly drain away through a tube, during the few hours it is becoming encapsuled?

You may say that the relief of tension is the primal object of the drain, but then that is obtained by the incision, as the fluid gushes out, and, besides, the dilution gained by the lavage and the retention of the salt solution minimize the risk to life, and with the Fowler position absorption is more gradual, thus permitting the excretory organs to carry away the toxins. Why not then give the patient, especially in a case where the endothelium is uninjured, the stimulation that occurs from free lavage of the peritoneal cavity, and leave within it a moderate quantity of salt solution, and close without a drain? By so doing our patient reaps great advantages should recovery follow, as a stronger scar is insured, with much less liability of a subsequent operation being required for the cure of a ventral hernia.

It seems to me that a drainage-tube is of use only until it becomes encapsuled, a few hours at best; that much greater tension can be relieved by incision and free lavage; that a greater quantity of pus can be removed by flushing than can possibly be carried away by a drain during the short time it takes to isolate it; and that the retention within the abdomen of the saline solution will very largely dilute the remaining micro-organisms, place the peritoneum in the most satisfactory conditions possible, and thus favor the elimination of toxins by the organs of excretion. For these reasons it would appear that it is perfectly justifiable to close the abdomen without a drain, unless it be one to the peritoneum, although I believe this is not essential, as if pus come from the wound it behaves as an ordinary stitch-hole abscess. Why are the results by drainage so discouraging, and why are the statistical reports not more uniform? Does the fault lie with the operator, in the method of treatment, or in the variableness of the virulence of the infec tion? In the cases of recovery, when a tube was used, the areas that were impossible to drain must have fought a successful fight, therefore it appears quite reasonable to infer that we can obtain a greater percentage of recoveries by free lavage, thus liberating the maximum of infective fluid, and closing without a tube, for if the undrained sections are capable of sustaining themselves when a tube has been used, surely the whole sac is equal to the occasion, after flushing until the return flow is clear and the abdomen securely closed. If we can obtain as good results from operative measures by this method as are secured by drainage alone, then this

procedure is the preferable one, for the reasons previously stated, as regards the strength of the resulting scar; much less liability to a ventral hernia; shorter time in bed; and the more rapid convalescence, owing to the change to better environment in the majority of cases, as most patients prefer home to hospital surroundings. The after-treatment is to follow the lines of elimination, and thus forestall, if possible, intestinal paresis. With this object in view, in about twenty-four hours, or earlier, if tympanites is present, a high 1, 2, 3 enema (turpentine 1 oz., Mag. Sulph. 2 ozs., glycerine 3 ozs., Aq. to one pint) might be used, after which a rectal-tube is allowed to remain within the sphincters for at least two hours at a time. If the enema is ineffectual, and the stomach will tolerate it, it might be well to administer one drachm of Mag. Sulph. in hot water every two hours until the desired result is secured.

Indiscriminate use of morphia in these cases is to be deprecated, for it masks symptoms, locks the secretions, and helps to induce what we endeavor to obviate, viz., intestinal paresis. Normal saline may be introduced into the rectum, or the cellular tissue and strychnia given if the heart action should indicate it. As soon as the functions of the digestive organs are restored nourishment would naturally be given on general principles.

91 Bellevue Avenue, Toronto.

Physician's Library.

A Text-Book of Surgical Anatomy. BY WILLIAM FRANCIS CAMPBELL, M.D., Professor of Anatomy at the Long Island College Hospital. Octavo of 675 pages, with 319 original illustrations. Philadelphia and London: W. B. Saunders Company, 1908. Cloth, $5.00 net; half morocco, $6.50 net. Canadian agents: J. A. Carveth & Co., Limited, Toronto.

We have perused this work with no little satisfaction. In the preface the author remarks: "Anatomic facts are dry only as they are isolated. Translated into their clinical values, they are clothed with living interest. No teacher can impart, or student assimilate, all the details of anatomy. The facts must be sifted, their comparative values fixed, and the reason for their acquisition demonstrated by directing attention to the practical problems with which they are associated. A fact that can be utilized is a fact that will survive."

Viewed from this standpoint, the work is very satisfying, and one which, on careful study, will well repay alike the practitioner and the student of medicine. We are inclined to think the title were better changed to "Applied Anatomy," for the wealth of anatomic facts revealed in this work can scarcely be relegated to the exclusive domain of surgery, inasmuch as no small part of the work is of equal value and interest to the physician. Professor Campbell in his excellent work may be said-in modern parlance-to have "delivered the goods," and it gives us pleasure alike to congratulate him on his work and to highly recommend it.

Published on the 15th of each month. Address all Communications and make all Cheques, Post Office Orders and Postal Notes payable to the Publisher, GEORGE ELLIOTT, 203 Beverley St., Toronto, Canada

VOL. XXXI.

TORONTO, AUGUST, 1908.

No. 2.

COMMENT FROM MONTH TO MONTH.

Original Articles practically at this season of the year make so much demand upon our space that in this issue we have devoted our pages to them alone. This is done in order that several who read papers at the Canadian Medical and Ontario Medical Associations may early see their papers published. As they are exceptionally good, scientifically as well as practically, we commend them to our readers without further notice.

THROUGH the kindness of Dr. Simon Flexner, anti-meningitis serum may be obtained on application from the Sick Children's Hospital, Toronto, together with directions as to use and limits, free of cost.