A saline purge may be given every morning, or, a combination of sodium phosphate, sodium sulphate, and sodium and potassium tartrate in teaspoonful doses three or four times daily. The object in an ordinary case is simply to keep the bowels loose. If the salines prove nauseating we may resort to compound jalap powder in half drachm doses, or elaterium can be given.

Perspiration is induced by using dry or moist heat. The former is applied by carrying hot air, through a funnel under the bed clothes, which are supported on a cradle. Moist heat can be given in the form of a hot bath for fifteen or twenty minutes and then covering the patient with hot blankets. The hot pack consists in wrapping the patient in a blanket wrung out in hot water, then a dry blanket, and covering with rubber sheeting.

There are some cases in which even these measures are futile in stimulating the sweat glands, and, if the patient's heart is in good condition, pilocarpine may be given in the dose of one-sixth to one-eighth of a grain to adults, and onetwelfth to one-twentieth to children from two to ten years of age. Some writers consider this drug very dangerous, but if the patient's condition is closely watched it may be used to advantage.

If signs of uremia threaten, as shown by great restlesness, mental stupor, foul breath, etc., we may supplement the measures already spoken of by hot water injections at a temperature of 120 to 150 degrees F., or a continuous irrigation with hot water may be employed.

For high tension in the blood vessels nitro-glycerine is given in the dose of one one-hundredth of a grain every two hours till its effect is noticed. Instead of this veratrum-viride can be given.

The definite factors in the production of uremia are still under dispute, but all agree it is due to toxins in the circulating blood. Phlebotomy, with the abstraction of twelve to twenty ounces of blood in a robust subject, will remove a portion of these toxins and seems a very rational treatment. The intravenous use of salt solution as a diluent is a further aid but

should not be overdone, as it is liable to cause pulmonary edema. Prevailing opinion has it that blood letting is not used often enough.

For convulsions we can use one-half drachm chloral and one drachm bromide per rectum repeated as often as necessary. Chloroform is also used but some authorities seem to think it is contraindicated. They base this on the fact that it is a renal irritant, as shown by the inflammation and necrosis following chloroform poisoning.

I have heard physicians criticize the use of morphia in uremic conditions, as it tends to lock up the secretions. Osler states that in restlessness and delirium, he considered it indispensable and that he has never seen any ill effects nor tendency to coma follow its use.

In the chronic forms of nephritis we should ascertain what the toxic agent is-infectious disease, over-eating, over-drinking (especially alcohol, coffee, tea), intestinal products, etc. If possible for the patient, we should advocate an easy life in some mild climate. According to Tyson it takes finer judgment to manage the chronic than the acute form.

There has been a great deal written in the last few years on dechlorination. Widal and his pupils have been the leaders in pointing out this practical aid in the treatment of nephritis with edema. It has been shown that if the kidneys fail to eliminate the chlorides, the excess retained passes from the blood to the tissues. As salt is hygroscopic, it takes up the water from the tissues and preserves by dilution the isotonic condition of the protoplasm. Widal has termed this chloruremia and it leads to multiple edema. In contradistinction to this, urea is retained in the blood itself and patients die of uremia without having any signs of edema whatever. These facts led to the application of a salt free diet to those cases of nephritis having edema. Milk answers this purpose very readily, as it contains a low percentage of chlorides. Five or six pints of milk may be taken daily. If distasteful, it can be flavored with a little coffee, or made alkaline with lime water. In some cases nothing else is given, in others a little cream cheese, milk foods, cream and fruits are allowed. Rice and

pastry can be given if no salt is added. Even a diet fairly rich in protein does no harm if salt is not used in its preparation. To summarize, the withdrawal of salt should be complete in nephritis with edema.

A great many drugs are used in chronic nephritis and there are a few which are very valuable if used when especially indicated. The theobromine-sodium-salicylate or diuretin is a renal diuretic and it not only increases the flow of urine but promotes the elimination of chlorides.

Tyson believes there is entirely too much iron used in this condition and that its exhibition should be confined to those cases in which anemia is pronounced. He used iodides as vaso-dilators and small doses of corrosive-sublimate well diluted.

The blood circulation should be kept at a medium tension. If too high, nitro-glycerine is administered; if low, digitalis is valuable, or caffeine can be given.

If the leaves of digitalis are prescribed, those of the second year growth should be specified, as they contain the active principles of the drug,

For headache cannabis indica is highly lauded, and with the addition of the bromides, it is said to be better than any of the coal tar derivatives. Dieula foy recommends the application of leeches back of the ear and fifteen to thirty grains of antipyrin daily.

The latter author states that in anuria we are almost helpless. He has used a solution called nephrin, which is made from the cortical substance of a bullock's kidney. In anuria of five days duration he has secured a good result.

Caution should be urged in using certain drugs on account of poor kidney elimination. For instance, I have observed three cases of mercurial poisoning following the exhibition of small graduated doses of calomel. The same thing occurred after two days' use of the diuretic pill containing calomel, squills and digitalis.

Medicated springs are recommended, such as the Poland, Bedford and Saratoga in this country. They have no curative value and simply act as flushes to the kidneys.

SURGICAL TREATMENT OF INTERNAL HEMOR

RHOIDS.

BY DR. H. W. DEIBEL, WILKES-BARRE, PA.

READ JUNE 14, 1911.

As the title indicates there is some injury to a part performed in which we may expect hemorrhage. Hemorrhage is really the definition of hemorrhoid. The surgical portion will be touched upon, not, however, to eradicate one particular form as the only procedure in the treatment of all piles, but reference will be made to some methods not commonly resorted to that will, I trust, be worthy of your consideration.

Each portion of the subject will be taken up and briefly outlined. For convenience and dispatch I have prepared the following table of the methods under above head: Crushing, Divulsion, Excision and Suturing the Wound, Sub-mucous Ligation, Whitehead's Operation, Ligature, Clamp and Cautery, Electrolysis, and Injection of Caustics.

Crushing. This is one of the oldest procedures in treating hemorrhoids. The word applied to this form of treatment indicates that some form of instrument is used to crush the pile. It is unnecessary to enter in detail a description of instruments used in this method. A crusher should be applied close to the base of the hemorrhoid in order to guard against a return of the trouble. The instrument being applied should be allowed to remain on the crushed pile for two or three minutes, which breaks continuity and prevents subsequent hemorrhage. Opinions vary in regard to the technique in this operation. Some authorities dilate the sphincters at the beginning of the operation and others advise that the attachment of the pile be severed at its muco-cutaneous origin. The piles should be crushed longitudinally and not transversely. The dangers attending the crushing operation are those of hemorrhage and sepsis.

Divulsion. This method, performed by using nitrous oxid gas, with oxygen, gives a temporary beneficial effect. It is advised especially in those patients who are suffering from strangulated hemorrhoids and those opposed to radical treat

ment. In administering gas a point that is of vast importance is here emphasized, that muscular action is not overcome as in the use of ether. Dilatation by means of gas can be more rapidly accomplished as the sphincteric rigidity acts as a guide in determining the force to be used. When used, an experienced anaesthetizer should administer it and the lips of the patient should be well greased.

The operation of divulsion consists in overstretching the sphincter muscle with either the fingers or the thumbs, or both, until all spasm and rigidity are overcome. Care must be taken not to tear the parts, as permanent incontinence may ensue.

In regard to the effect of divulsion upon constipation and in permanently establishing regularity of the bowel movements, some practitioners have gone so far as to believe that divulsion can and will cure constipation, and the operation has been frequently recommended and performed for the purpose of overcoming this condition. In ordinary cases of constipation it is not believed that the use of this method has any such results.

Constipation is due to a number of causes and conditions and these must be corrected and overcome before satisfactory results can be expected. In those cases in which piles alone are present and by mechanical action have irritated the sphincterin to a condition of hypertrophy, causing obstruction, may we expect divulsion to be followed by a satisfactory outcome.

Excision and Suturing the Wound. There are many modifications of this method suggested by various advocates. All of them have as the underlying principle, the excision of the hemorrhoid by the scissors or knife, and the uniting the wound by buried sutures of one kind or another. The great danger, and to many an objection to this procedure, is that all sutures employed within the bowel, no matter how close the apposition of the wound, lead to infection at the point of entrance and as a result abscess and fistula are likely to follow. Patients so treated are subjected to a good deal of pain afterwards. One, two and three piles may be successfully removed by this method, but when more than that number exist, as frequently happens, the complete removal of the last one or two is rendered almost impossible, owing to the narrowed field in which