may not be injected into the cavity. Suction must also be taking place when the needle is rapidly removed.

WET CUPPING

This method is now rarely used to withdraw blood from the body. It is generally much better to use leeches for local bleeding, or venesection for general bleeding. When wet cupping is done the skin is made surgically clean, and generally the better method is to apply a dry cup for a few minutes first, then remove the dry cup, and puncture or scarify the skin just enough to cause oozing of the blood. The cup is again applied, and is retained in position as long as the blood continues to flow. Wet cupping should not be done to feeble patients.

LEECHING

This is a method of causing depletion by the abstraction of blood; generally, however, other methods are better. Although leeches occur in American brooks and streams, the imported leech is the one that is most efficient, and the Swedish leech is perhaps the best, and will draw sometimes as much as twenty mils of blood, while the American leech will not draw half that amount.

The best method of applying a leech is to place it in a glass tube of proper size, open at both ends, termed a leech glass. The leech is thus directed to the exact spot at which it is desired that it bite. The skin should be cleansed and a little sweetened water or milk rubbed on this spot to hasten the leech to fasten its teeth into the skin and begin its suction work. Leeching should not be done on the face, as slight scars may be left. The leech secretes a liquid which prevents coagulation of the blood, and for this reason sometimes when the leech is removed, bleeding persists, unless pressure is used to stop it. Generally several leeches are applied in a small area around the part at which local bleeding is desired. If for any reason it is advisable to remove the leech, it can be made to let go by dropping a little salt on it; it should not be pulled off.

Leeches are frequently applied back of the ear, in inflamma

tions of the middle ear and mastoid; they are used on the back of the neck in meningitis, and may be applied to the temples in inflammations of the eye, although, as just stated, they may leave scars. They are sometimes used in acute inflammations of the throat and they may be applied to the groin for inflammation of the testicles.

VENESECTION

Blood-letting by phlebotomy has an ancient and harrowing history and fell legitimately into disrepute. However, there are conditions in which venesection is advisable and even lifesaving, and it should doubtless be resorted to more frequently than it is at the present time.

Venesection is generally done on one of the veins at the inner surface of the elbow, and the method of procedure is as follows: the skin is made surgically clean, perhaps best with iodine, and a bandage is placed tightly around the upper arm so as to retard the venous flow, and not to interfere with the arterial flow (the veins generally quickly become prominent, as the conditions for which blood-letting should be done are generally the conditions in which there is a surplus of blood in the circulation); the forearm is then grasped firmly with the left hand, the thumb and finger pulling the skin tightly over the swollen vein, either the median basilic or the median cephalic being the vein selected; the vein is then punctured with a trocar needle, similar to the lumbar puncture needle. The amount of blood to be withdrawn depends entirely upon the condition, and the pulse at the wrist of the other hand shows when the blood-pressure has sufficiently dropped. Or, the blood-pressure of the patient being known, it may be taken again by an assistant, and when a sufficient fall has occurred, it will indicate that the bleeding should cease. If the blood should cease to flow, it shows that a slight clot has probably occurred, which may be gently wiped away with sterile gauze. When enough blood has been withdrawn, the bandage is removed from the arm. Sometimes an incision is made in the skin and before the vein is punctured or incised a stitch is passed through the skin, to be later fastened after the operation is completed. Needless to say, the

whole operation and the instruments used must be surgically clean.

In infants where the veins are not easily located, even with dissection, a perfectly simple and safe procedure is to puncture the superior longitudinal sinus. This is best reached by introducing a needle with a plunger at the posterior angle of the anterior fontanelle. The needle should be graduated, and the depth to which it is introduced depends upon the age of the child and the thickness of the skin and fascia, usually from 316 to 516 of an inch. The longitudinal sinus lies directly under and is adherent to the overlying tissues, consequently the lessened resistance is noted the instant the sinus is entered. Removal of the plunger permits the blood to come through the needle. This method is also employed in giving intravenous medication to infants.

The usual surgical asepsis must be observed and enough assistance must be had to keep the infant's head absolutely quiet. Special instruments have been suggested and used for carrying out the technique.

The indications for blood-letting are high pressure sufficient to endanger the cerebral arteries; it is doubtful if venesection is advisable after an apoplexy has occurred. It has been done in plethoric individuals in the first stage of pneumonia when the patient was likely to die from congestion in both lungs; also sometimes with benefit in a later stage of lobar pneumonia, when there is a serious damming back of the blood into the right ventricle. There would rarely be any indication for venesection in influenzal pneumonia. When there is damming back of blood in the lungs and acute dilatation of the heart in valvular disease, life may be saved by venesection and coincident administration of ergot intramuscularly. Venesection is advisable in some forms of sunstroke with high pressure and a strongly acting heart. In uremic conditions with high bloodpressure and danger of apoplexy or sudden dilatation of the heart venesection is indicated, also it may deplete the blood of irritants that cause convulsions and coma. In puerperal eclampsia, unless there has been profuse and free bleeding from the uterus, venesection should be done.

INTRAVENOUS INJECTION OF SALINE SOLUTIONS These injections are generally given, as in the transfusion of blood, into the median basilic or cephalic vein at the elbow. The skin is made surgically clean, often best with tincture of iodine; the upper arm is constricted by an elastic or other bandage sufficiently to stop the flow of blood in the veins; the arm is held firmly with one hand and the skin pulled tightly over the dilated veins at the bend of the elbow; the proper needle for this purpose is then plunged upward slowly through the skin into the vein; it should not be plunged too rapidly through the tissue as it is likely to slip over the side of the vein or pass clear through it. Many times it will be found, because the circulation is very poor or the arm is fat, that the vein cannot be discovered by the above method, and an incision through the skin is necessary to expose it. The vein being found, the needle is then inserted as before, and later the incision in the skin is stitched. When thus ready for injection the bandage is removed from the arm. If any swelling should appear around the point of injection, the injection being given slowly, it shows that the needle either has not penetrated the vein or has gone through it, and that the fluid is being forced into the tissues. When the injection is completed, the needle is rapidly withdrawn, the site of the puncture pressed for a moment, and the part sealed with collodion.

The solution to be injected should be what has been termed a physiologic saline, namely, 0.9 per cent. of sodium chloride in warm sterile water. A so-called "normal" saline solution is one containing 0.6 per cent. of sodium chloride, and a "decinormal" solution is one that represents 10 of this strength. The solution for injection should be accurately and not carelessly made, unless there is some great emergency, when a teaspoonful of common salt to a pint of boiled water may be used. Too weak or too strong sodium chloride solutions damage the blood corpuscles. When possible, fresh sterile distilled water should be used rather than boiled water. Generally still better is a solution containing the following salts, which makes the content of the solution more or less like the salt content of the blood serum, namely:

Sterile tubes containing these salts in the above proportion and in just the amount sufficient to add to a quart of sterile water can be obtained. The proper apparatus, needle and clamp for these injections, and the technique can be learned in the clinical laboratory and in the hospital service.

Care should be taken that the air is completely expelled from the tube and needle before the injection is made. The reservoir should be held only about a foot above the arm so that the injection will not proceed too rapidly; it should take about thirty minutes to inject a quart of fluid. Too much liquid injected, if the circulation is weak, may cause edema of the lungs.

Saline transfusion is now less frequently done than before the transfusion of blood became so successful. The indications for the use of saline transfusion are: when there is hemorrhage and the transfusion of blood is not possible; in serious infection to keep the vessels well filled and thus prevent absorption of toxins; and when there has been great loss of fluid from the body, as in cholera and some cases of infantile diarrhea. In diabetic coma sodium bicarbonate solutions should be given intravenously after venesection and the withdrawal of a considerable amount of blood. Also in uremic convulsions the patient may be bled and then warm physiologic saline injected, unless there is anasarca. To prevent and to combat diabetic coma and acidosis an intravenous injection of 500 mils of a 4 per cent. solution of sodium bicarbonate should be given. As in sterilizing this solution some of the bicarbonate becomes the more irritant carbonate, before it is injected sterile carbon dioxide gas should be passed through the solution to reconvert the carbonate into the bicarbonate of sodium.

The amount of fluid injected may vary, but probably should never exceed a quart, and, as above stated, the injection should be made very slowly. If there is general edema, or there is edema of the lungs, saline transfusions should not be given.