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the notch was important from the standpoint of clinical diagnosis. Surgical Considerations of Splenectomy. — Dr. W. J. Mayo of Rochester, Minn., said that the safety of splenectomy depended on careful separation of the at- tachments of the spleen and the delivery of the organ without injury to the vascular pedicle. A longitudinal incision was made through the upper half of the rectus muscle, extended obliquely along the costal margin about an inch and one-half from it and up toward the ensiform cartilage. The longitudinal part of the in- cision might be carried down to any desired length. Adhesions especially over the upper pole were occa- sionally vascular. It was best viagra substitute to separate these vessels with the fingers as close to the spleen as possible. Some- times the adhesions were so strong they must be divided by a cutting instrument. The bulk of the vascular at- tachments (vasa brevia) in the gastrosplenic ligament could be delivered with the spleen, the stomach being partly withdrawn from the abdomen before separating the ligament. In a large, adherent spleen the deep vas- cular connections might anastomose with the vessels along the spine and the crux of the diaphragm. These must be separated before the spleen could be evis- cerated, hemorrhage being controlled by a carefully adjusted gauze tampon. The application of this gauze tampon temporarily to control bleeding from the deep attachments was very important as the success of hemorrhage could not be seen and controlled until the spleen had been removed. The tail of the pancreas, if present, should be separated from the splenic pedicle, its bleeding points ligated, and the gland dropped back. In three splenectomies the speaker had tied off a portion of the tail of the pancreas with the splenic pedicle without any harm resulting. Usually the vascular pedicle could be cleared and ligated in sections. The arteries should be tied first but all vessels should be tied before any portion of the pedicle was cut. If the pedicle was short, it might be grrasped with elastic rubber-covered clamps, thus avoiding damage to at- tached viscera, such as the gastric wall, until the ves- sels could be secured. The two-forceps method of liga- tion was very satisfactory: two forceps were placed three-fourths of an inch apart on the pedicle and the spleen cut away without regard to back bleeding. A catgut ligature was thrown around the pedicle below the proximal forceps which was then loosened and the ligature tied in the compressed area, while the distal pair of forceps steadied the pair and prevents retrac- tion. A second ligature made the pedicle secure. Closure of the splenic space was important if there was any oozing of blood. Compression with the temporary tampon would seal the smaller vessels in a few minutes but deep in the wound other vessels might require fur- ther treatment. With catgut on a small curved needle,- the raw space beginning at the tied splenic vessels was closed as well as possible by cateut sutures which com- pressed the bleeding vessels. The mortality depended more on the condition of the patient than on the techni- cal difficulties of operation. But 5 of the 57 patients sub- jected to splenectomy died in the hospital, and autopsy showed that two of these deaths were from preventable causes — hemorrhage and sepsis. (To be continued.) Medical Record H A Weekly Journal of Medicine and Surgery Vol. 88, No. n. Whole No. 2340. New York, Septei\iber ii, 1915. $5.00 Per Annum. Single Copies, 1 5c. ©rtgtnal ArtirlfB. BLOOD TRANSFUSION." INDICATIONS AND TECHNIQUE. Kv GKOPalE 1. .MJl.l.lOR. M.D. BROOKLYN, N. Y. The paramount interest in the technique of blood free viagra samples by mail transfusion in the past few years free viagra samples by mail has free viagra samples by mail stimulated me, in viagra substitute addition to a good many others, to focus my attention to this important subject. It is my purpose, in this communication, to bring together the various methods of blood transfusion and briefly to allude to some contrasts between the complicated inaccurate and unscientific apparatuses of the past and that of the ideal simple devices of to-day. From a study of the literature and from observa- tions of the practice by different men, I have ob- tained certain impressions of many of the numer- ous methods of blood transfusion free viagra samples by mail now in free viagra samples by mail vogue. In addition to the authorities with their respec- tive methods, which will give a panoramic impres- sion of the .subject, I will refer to some of my own ideas and work on the subject in hospitals, in out- side private free viagra samples by mail practice, and in my office. Periodically, since the knowledge of the circula- tion and the value of blood has been established, different clinicians have advised blood transfusion with the hopes of saving life, or to hasten a pa- tient's recovery. As early as the days of Colum-