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marked increase in urinary flow: the effective dose is limited by its toxic action on respiratory centres. Practically, excess of caffeine induces only the first stage; excess of ulexin only the second.

B. Substances that dilate the kidney, but to less extent and more slowly than caffeine and ulexin, are dextrose, urea, sodium, chloride and acetate, and probably all constituents of the urine.

C. Drugs that contract the kidney without subsequent expansion: (1) Digitalin, with increased secretion of urineprobably resulting from general heightened blood pressure; (2) Spartein, with diminished secretion-in health at least; (3) Strophantin causes slight temporary contraction, with no marked increase of secretion; (4) Apocynein, similar temporary contraction, and no definite increase of secretion; (5) Turpentine; (6) adonidin, and (7) varium chloride, give similar results. In conclusion, it seems to us that the plethysmographic method of experimentation is a valuable one for determining the exact action of drugs on the circulation, and one that deserves more attention than it has hitherto attracted.

LIGATURES ON THE LIMBS DURING SURGICAL OPERA

TIONS.

The procedure of applying tourniquets or elastic ligatures close to the trunk, on the limbs of patients, before making important surgical operations, has been in use for some years. The late Dr. Post, of New York, is credited with being the first one to make use of the method. His object was to control hæmorrhage, and mitigate the shock of the operation. It was for this purpose that Dr. Aikins, of Toronto, first employed the rubber tourniquet, some eight years ago. He applied the elastic sufficiently tight to obstruct the venous circulation, without stopping the circulation in the arteries. Dr. Aikins soon discovered that when he made use of the method, the patients were more easily put under the influence of the anaesthetic, and that the quantity of ether or chloroform required to anesthetize the patient was very small, that consciousness returned quickly, and that the after effects were not so persistent or distressing.

Recently the procedure has been receiving considerable attention, particularly with the surgeons of New York. Dr. Corning, in a letter to the New York Medical Journal, explains how he was led to make the first application of the elastic tourniquet, for the object of diminishing the time required to etherize a

patient. His method arrests both the venous and arterial bloodflow in the limbs, which results in reducing the quantity of blood to be saturated by the ether or chloroform, in order to produce anæsthesia.

In a more recent number of the same journal, Dr. Sweetnam, of Toronto, states that he has seen Dr. Aikins make use of the procedure, and has used it in his own practice for several years. He follows Dr. Aikins' method of only arresting the venous flow; in this way, "besides cutting off from the active circulation the amount of blood normally found in the limbs," there is drawn off a large quantity from the head and trunk, lowering decidedly the pressure in these parts.

Dr. Sweetnam claims for the procedure the following advantages, and calls attention to the precautions to be observed:

ADVANTAGES.

(1) But little time is lost in securing complete anesthesia, and but little in waiting for returning consciousness before leaving the patient, the operation being completed.

(2) If the bands are applied ten or twelve minutes before the first incision is made, the operation will be a comparatively bloodless one, and the surgeon works more rapidly and more comfortably than he would if the hæmorrhage were more severe. (3) Saving of blood to the patient.

(4) If collapse appears to threaten the life of the patient, the removal of one or more of the ligatures can be relied upon to bring about a prompt reaction.

(5) There is less vomiting and distress after the use of the anæsthetic.

(6) The small amount of ether or chloroform used, from an economical stand-point.

(7) Fewer ligatures and compression forceps are required to control bleeding.

(8) Less embarrassment of lungs and kidneys, and lessened risk of serious injury to these organs if diseased.

PRECAUTIONS.

(1) In cases where there is a history of purpura, it is well to exercise care both as to the amount and as to the duration of the constriction.

(2) Where there are marked varicosities of the limbs, these should be supported by rubber or flannel bandages.

(3) Where there is no contra-indication, inasmuch as the amount of blood supplied to the heart and cerebro-spinal sys

tem is materially lessened, the effect may be somewhat depressing, and for that reason ether would appear to be the better anæsthetic.

I have frequently used chloroform with the ligatures, and so far without noting any unpleasant results; but, whichever anæsthetic is used, the head should lie low, and, if alarming symptoms should develop, I should draw the patient up so that the head would hang over the end of the table, and at the same time loosen several of the ligatures.

(4) If the wound, still open, is watched for five or ten minutes after the removal of the ligatures, its color will be seen to deepen very distinctly from the increased quantity of blood flowing to the part. Now clots, which were sufficient to seal effectually the small vessels while the ligatures were in position, may give way under the increased pressure; in one case, thirty minutes after the removal of a breast, violent hæmorrhage set in, necessitating the reopening of the entire wound to secure the bleeding points. If, however, the bands are removed as soon as the last incision is made, there will be but little risk of any mishap of this kind after the sutures have been introduced and the wound has been securely closed.

(5) The constriction may with perfect safety be kept up for two hours, but it is well to keep the limbs wrapped in blankets, and thus prevent any serious loss of heat.

TREATMENT OF STRANGULATED HERNIA.

At the meeting of the New York Academy of Medicine, December 15, Dr. I. H. Burchard read a paper on "The Modern Treatment of Strangulated Hernia."

He said that, encouraged by the remarkable successes obtained in the treatment of non-strangulated hernia by the methods suggested by Banks, Czerny and others, surgeons had latterly paid special attention to the radical cure operation as applied to cases in which strangulation existed, and the results achieved had been most gratifying. The general principles upon which, as a legitimate surgical procedure, the operation was based, were the following:

(1) A more general recognition by the profession of the value of time in the earlier stages of the strangulation; so that surgical relief could now generally be rendered before pathological changes, which were irremediable, had taken place in the tissues.

(2) Modern herniotomy implied an abandonment of those uncertain and pernicious methods and practices which, founded on false pathology, had sought to relieve the strangulation by producing a condition of systematic relaxation. It was now recognized that spasm, as a causative agent in the production of strangulation, never exists.

(3) Modern herniotomy restricted the employment of taxis to within limits which were rational and safe. Necessary as properly directed taxis was in the reduction of strangulated hernia, by its indiscriminate and reckless use irreparable damages had not infrequently been done in the intestine; and he could not but feel that it had been a misfortune to designate by a special appellation the manipulations employed in reducing hernia, since the practice had exaggerated their importance in the treatment, and been a fruitful source of abuse.

(4) Modern herniotomy implied the early resort to a cutting operation. Many lives had to be sacrificed before the profession seemed to realize that the gangrene and ulceration, the fæcal extravasation and stercoraceous vomiting, the peritonitis and collapse, were not necessary and integral portions of the primary conditions of strangulation, but secondary complications, developing later in the progress of the diseaae, and the legitimate result of delay in affording relief to the original constriction. If, however, the strangulation were relieved before inflammation of the gut or adjacent tissues had supervened, these grave dangers could be avoided. The practice advised by Dr. Burchard was, if possible, to cut every case of strangulated hernia in which gently applied taxis under anæsthesia, preceded, as a rule, by the application of ice, does not yield reasonable expectations of success within about one hour after positive symptoms of strangulation have presented themselves. In his opinion nothing was gained by delay, while everything was risked.

(5) Modern herniotomy was an antiseptic operation, demanding the fullest application of Listerian principles.

(6) Modern herniotomy required in the disposition of the hernial sac the finest impartiality of judgment. Certain cases required incision, while in others the strangulation could be readily reduced without opening the sac; so that it would be folly to thus complicate the operation and expose the patient to unnecessary danger.

(7) Since Mitchell Banks, of Liverpool, had urged the possibility and expediency of perfecting the old operation of kilot

omy, so as to add to the operation done for the relief of strangulation the inestimable advantages of an operation for radical cure, the strongest possible encouragement had been given for the attainment of an early, thorough and perfected operation.

Regarding the special treatment of strangulated hernia, Dr. Burchard said that he had nothing novel to add to the excellent recommendations already published on that subject. His experience had led him to the adoption of a plan of treatment substantially as follows:

(1) Pain allayed, vomiting quieted, and nervous tranquility secured by hypodermic administration of morphia with atropia. (2) As soon as practicable, a careful examination is made of the hernial tumor; any attempt at reduction being studiously avoided.

(3) If evidences of local inflammation are present, or if there is much swelling of the tumor, a poultice of flax-seed meal and cracked ice, or the ice coil is at once applied; these being dispensed with, however, if the patient is feeble or the strangulation is of long standing.

(4) A stimulating enema of turpentine and oil or a large emollient of thin flax-seed is administered, and the rectum thoroughly washed out. Should it be required, the patient is catheterized. If the tumor is at all disturbed, no attempt at taxis is made until the patient is anæsthetized; permission having first been obtained to proceed with the operation in case taxis should fail.

At this point Dr. Burchard said he wished to emphasize the advantages to be gained by putting the patient under full anæsthesia (preferably by chloroform), covering the tumor with a rather large and heavy ice poultice, elevating the lower extremities, and keeping the hands entirely off for a period of from thirty to forty minutes.

In a number of instances thus treated he had had the satisfaction of seeing the tumor almost imperceptibly slip back of itself, even after prolonged taxis had been unsuccessfully employed. As to just how long the attempt at reduction by taxis was justifiable, no absolute rule could be laid down. To the practised touch a moment was sometimes sufficient to determine the possibility of a successful reduction. In other cases it was advisable that the trial should be prolonged for twenty, or even thirty minutes, provided always that only the gentlest manipulations were employed.

Taxis having proved unsuccessful, the operation should at

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