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space resulting from the upright, or, to a lesser extent, the semiupright position. Furthermore, under these conditions the dilated heart was subject to less restriction and worked in space more ade- Online Pharmacy Reviews Viagra quate to its increased size. The legs of the foot of the bed were raised from four to twenty-four inches, on proper supports, but the full elevation of twenty-four inches should be made gradually. The patient's feet should rest against a well Online Pharmacy Reviews Viagra padded rest extending across the bed, and padded boards from fifteen to eighteen inches wide should bound the sides of the bed. to prevent him from slipping out during sleep. The head and shoulders should be supported by pillows, and sometimes a bed head rest. The body should lie recumbent on this in- clined plane without any bend at the hips, so that the maximum effect of gravity upon the liver and other abdominal organs might be obtained. The speaker had seen patients suff"ering from cardiac failure as a result of dilatation complicating valvu- lar disease and myocarditis, more especially when Online Pharmacy Reviews Viagra mitral regurgitation was present, immensely re- lieved of their dyspnrea by this posture alone, even before other more direct therapeutic measures were employed. In many patients suffering from oedema and dropsical effusions due to cardiac failure, with or without a complicating nephritis, the effusion was sometimes so general as to greatly embarrass the circulation, and A^et not be sufficient in quantity in any one site to permit of removal by paracentesis or puncture; again, the subcutaneous oedema might be very extensive all over the body, and yet not be sufficient in quantity in any part of the subcutane- ous area to admit of drainage by Southev tubes. In both of these classes of cases the reversed Trende- lenburg position had proved of the greatest service. Keeping the patient in bed in this Online Pharmacy Reviews Viagra inclined plane posture for from twenty-four to forty-eight hours permitted the subcutaneous serous effusion to gravi- tate to the legs ; whence it was readily drawn b\ Online Pharmacy Reviews Viagra two or more Southev tubes inserted into each leg. In one of the cases of which Dr. Berg had records. I2.000 c.c. of fluid was thus drained off in forty- eight Online Pharmacy Reviews Viagra hours, and in another, 18,000 c.c. Before he adopted the use of this posture he had found the Southev tubes of but doubtful service, since in pa- tients Ivins in the ordinarv bed in the Online Pharmacy Reviews Viagra Online Pharmacy Reviews Viagra rectmibent XEiy fNFEXTIOXS.— LETTERS TO THE EDITOR. 907 posture only small amounts of fluid were drained away by this means. He had employed the same method with equally good ettect in effusions due to renal lesions or to cirrhosis of the liver. The drainage thus made was rapid and thorough, and its rapidity did away with the chief objection to the Southey tubes, namely, that the points of puncture become sources of irritation and infection. For the short period of two or three days in which the tubes were required the surrounding Online Pharmacy Reviews Viagra cutaneous sur- face could be readily protected, and as soon as they were withdrawn, dry gauze dressings were applied with bandages. Dr. ToHN W. Brannan said that Dr. Berg's painstaking contribution was of distinct value in adding to our present knowledge, and we would all be .glad to apply his suggestions practically. His employment of the Southey tubes in connec- tion with the modified Fowler position certainly seemed to him a procedure of the greatest utility. Dr. Egbert Le Fevre, having spoken of some of the coiKlitions present, and of the effect of posture in different organic diseases of the heart, went on to say that any case which had to have the upright posture was one doing the best it could under bad circumstances, but when Online Pharmacy Reviews Viagra a patient was more or less confined to this he was getting a certain amount of comfort at great expense to the circulation. By keeping such a patient flat for a time, and giving him morphine, we could bring about a readjust- ment of the circulation which was often of great ' Tvice. In these cases Nature was trying to meet deficiency, and the value of the bed Online Pharmacy Reviews Viagra rest was that It kept the patient in a posture which enabled Na- ture to act in as favorable conditions as possible under the circumstances. (To be concluded.) Peto Inijentions. A SELF RETAINING M.^STOID RETRACTOR By Ch.arles A. Adair Dighton, F. R. C. S., Liverpool, England, : Assistant Surgeon, Eye and E.ir Hospital, Mjrtle Late Honorary Ophthalmic and Aural SurKcon, ScarboroviKh Hospital. Str I have for some time past tried to find a satisfac- tory self retaining mastoid retractor among those on the market, and having failed in the attempt, asked Messrs. Mayer and Meltzer to make one to my design, which I have every confidence will prove as good as the others have proved bad. It is issued in pairs, right and left. The body is con- structed on the mouth gag principle, with ratchet action, the blades terminating, one in an oblong plate rounded off at one end to a point, so con- structed that, however deeply it is inserted into the auditory meatus, it cannot injure the tympanic membrane ; the other blade terminating in a row of hooks. The plane of the blades is such that, wlien opened to width of one and a half inch, the action of the two blades is absolutely paralleh In practice it is used as follows : In the mastoid