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the superintendent being looked upon as the jailer. Happily, a change was rapidly taking place, and such in- stitutions were very properly coming to be looked upon as hospitals. Many patients realized their condition and wished, as did their friends, that they might enter the hospital for treatment if the odium of incarceration could be removed. In some State institutions (Connecticut and Massa- chusetts) voluntary commitment was provided for un- der certain restrictions. In New York there was a sim- ilar provision in regard to homes for the insane, but in State institutions a legal commitment was called for, and the patient could not leave the hospital at will. The superiority of voluntary commitment in certain cases was striking, and it made provision for a class of patients who, under the technicalities of the law, were not ad- mitted to the State asylums at all. It was in cases on the border line of insanity that voluntary commitment was most needed and proved most useful. The paper was discussed by Drs. Lester, Colvin, Fer- guson, McLeod, and Strong. Dr. Lester gave an in- stance of injustice in the working of the new law, but others explained that this was due to the rules established by the Commissioners in Lunacy or obstinacy of the asy- lum superintendent, and not to any fault in the legisla- tive enactment. The Treatment of Enteric Fever. — Dr. Gustavus Eliot, of New Haven, Conn., in presenting this paper, said Purchase Ziprasidone Online he had nothing new to offer, but wished to impress the superiority of certain recognized methods over others. The patient should be put to bed and not be allowed to get up until all doubt was ended as to the nature of his disease, or until recovery, if it were really typhoid. Fresh cow's milk was the best food. Give at least two quarts a day. There were some therapeutic annihilists ; to them he did not address his further remarks. He ad- vised three to five doses of ten grains of calomel at the outset, with forty-eight hours' interval. Quinine might be given if one suspected malaria, but probably nine cases out of ten would be as well off without it as with it. Salol had been proven to be without value. Turpentine was useful in tympanites, and it strengthened the nervous system. He used iodine and carbolic acid. They should be administered early, and might be continued until con- valescence. As to Buy Ziprasidone Online the Brandt or tub- bath method, he ventured to say it would never be carried out in country districts. Those who applied it must turn a deaf ear to the piteous appeals of the sick to be spared the discom- fort. Antipyrin and other similar Purchase Ziprasidone antipyretics had un- doubtedly been the means of saving many lives in enteric fever. Stimulants were seldom indicated at the begin- ning, and should not be given by routine. Dr. Douglas deprecated the too free use of stimulants in typhoid. Among agents used by him were creosote and calcined magnesia ; ten grains of calomel repeated not oftener than three times ; salicin ; no quinine unless there were malaria ; subnitrate of bismuth often took the place of opium. Dr. William Finder took the fat from milk when the pure article could not be digested. Resorcin was valua- ble. Dr. Lester said malaria prevailed where he lived, and it was at times difficult to decide whether the patient was suffering from this affection or typhoid. Quinine was apt to be useful, and doctors from a distance, when called in consultation, were apt to err in prohibiting its use. Dr. E. R. Sijuiiiii, of Brooklyn, said he never lost op- portunity to repeat the fact that calomel was converted into an albuminate in the stomach, but a small amount became bichloride and was perhaps antiseptic in the in- testine. If there were Order Ziprasidone Online much fluid in the stomach it was apt to be carried along too fast. Take the dry powder on the tongue. Dr. Martin gave no quinine, as there was no malaria where he lived. Feed the patient. Rare Forms of Gout and Rheumatism. — Sir James A. Grant, of Ottawa, stated by way of preface to his paper, that in Canada they watched with the greatest interest the work of the medical profession in the States. It was gratifying in the highest degree to con over such names as Rush, McDowell, Gross, and a host of others. He then gave the histories of some cases of rare forms of gout and rheumatism, one being a case of pneumonic gout, one of gouty perityphlitis, another of rheumatic typhlitis or perityphlitis, in each instance the pneumonic or typhlitic symptoms disappearing with metastasis of the diathetic disease to the joints. Let the people be edu- cated to simplicity of living, so that the functions of the body might be carried on in a normal and healthful man- ner. Surgical and Pathological Memoranda. — Dr. Donald McLean, of Detroit, related some interesting cases from ~ a surgical and pathological stand-point. Some were cases of ununited fractures of long bones. It seemed the chief October 21, 1893] MEDICAL RECORD. 539 cause of non-union in such cases had commonly been overlooked, i.e., that the blow Purchase Geodon producing the fracture had been direct and severe. In -all old cases his treatment had come to be limited to two procedures : If possible, application of a splint or support ; or amputation and an artificial limb. In amputation at the hip-joint he rendered the parts bloodless by a tourniquet compressing the ab- dominal aorta beneath the umbilicus. One case of hip- joint amputation following a severe injury was related, the patient recovering. He also related two or more cases of amputation of the whole shoulder after ligating the main vessels. Two well-marked cases of spina bifida had come under his care in which treatment by iodine injections followed by excision of an elliptical flap effected a cure. Two cases of tumor of the median nerve of Buy Geodon the arm were cited in which he performed excision successfully, in one the tumor proving to be a cyst as large as an orange. In both of these cases the patients were chloroformed and went into collapse from which it was difficult to arouse them, causing him greater anxiety than he had ever be- fore experienced during thirty years' use of this an£e,sthetic. Eleven years ago he amputated the breast of a Buy Ziprasidone patient for Buy Cheap Ziprasidone scirrhous cancer, the diagnosis being confirmed clinically and microscopically. There had not been any return. Buy Geodon Online Five years ago he amputated her son's tongue for carcinoma and there had been no return. The reader showed a large and very irregular gold plate which a man had swallowed while asleep, and which by good luck he caught with the forceps introduced some five inches down the cesophagus and extracted it. One could not conceive of a form in which the foreign body would have been more difficult to remove, yet, as it happened, little trouble was experienced. Discussion on the Treatment of Appendicitis. — Dr. Frederic S. Dennis, of New York, read a paper, open- ing the discussion, in which he propounded the following questions : i . What proportion of cases of appendicitis end in resolution ? 2. What class of cases require imme- diate operation ? 3. What class of cases do not require immediate operation ? Order Geodon To formulate precise and satisfactory answers to these questions was not an easy task. There was no unanimity of opinion as to the exact time when an operation should be performed. During the last two years the pendulum had swung so far in one direction that it had begun to swing in the opposite direction. There was an honest diversity of opinion, it tending on one side toward ex- treme radicalism, on the other toward extreme Ct)nser\'- atism. About one-half to two thirds of cases of in- flammation in the right iliac fossa underwent resolu- tion. An immediate operation was called for if the symptoms went on after the third day ; an immediate operation was not called for if, after the second or third day there was general subsidence of all the symptoms. There were, of course, exceptions to all general rules in surgery, and he could conceive of cases where an opera- tion was called for within twenty- four hours. It should be remembered that there Cheap Geodon were several varie- ties of inflammation in the right iliac fossa independent of appendicitis. Then it had been argued in favor of in- terference that removal of the appendix removed the pos- sibility of subsequent appendicitis. .\s a matter of fact, however, there had been cases in which the attacks con- tinued after removal of the appendix. It should be remembered, too, that there were many other conditions which had been mistaken for appendicitis, and in which abdominal section would have done harm. Then there was great liability of hernia following the operation. A prominent instrument-maker said he had sold six dozen trusses during (he last j'ear for hernia following operations upon appendicitis. McBurney's point was a valuable sign, yet it was sometimes present where appendicitis did not exist. Dr. J. W. S. GouLEV had seen in all about two dozen cases of appendicitis which ended in resolution, and only two or three which had come to operation, and then suc- cessfully. They were perityphlitic or typhlitic. Dr. Donald McLean, of Detroit, related some inter- esting cases in his city, which showed that the questions were of the most serious which we were called upon to answer. In some, an operation had been recommended, was rejected, and the patients got well ; in others, an operation had been done and death ensued ; in still others it had been followed by recovery. The eyes of a critical public were upon the profession in this matter. In one instance he opened the abdomen at the request of a girl who had long suffered from a " pain in the side," and was about to give up his search for the cause when he happened to feel a band, and tracing it up it was found to be an elongated appendix vermiformis which had be- come adherent to the inflamed ovary. Dr. Joseph D. Bryant said there was a difference be- tween the questions, what proportion of cases of appen- dicitis ended in resolution ? and what proportion of cases of pelvic inflammation ended in resolution ? The answer to the former question, however, could only be estimated from that of the latter. According to Fitch about fifty per cent, of cases of inflammation about the caput coli ended in resolution. But could a case recover by resolution if there were gangrene of the appendix ? or perforation ? or abscess ? He thought not in the sense of complete recovery. Then in what percentage of cases of inflam- mation in the right iliac region did abscess, gangrene, and perforation take place ? He was asking questions which he was himself unable to answer. Again, could we diagnosticate gangrene, abscess, and perforation in time to do an operation ? Assuming from the history of a case that one of these conditions was present, he would operate at once, whether the case were one day or several days Generic Ziprasidone old. Temperature was an unreliable guide, continuous local pain and tenderness, muscular rigidity, and tympanites were important signs of perforation. Regarding the McBurney point, it was valuable when present, but to expect pain in this particular place was unreasonable, as autopsies had shown that the caput coli varied greatly in locality. Dr. John A. Wveth thought that where one was in doubt it was safer for the patient to operate. Nor did he think that he was biased in favor of interference. True, many cases got well by resolution, but suppose there were one hundred persons with appendicitis on the right hand and one hundred on the left ; that all the former were operated upon by an able surgeon, while the latter were not : which list would show the largest proportion of recoveries ? As to hernia, it was due to late operations, the presence of suppuration, and inability to close the wound. With a timely early operation the Order Ziprasidone wound could be closed and hernia avoided. Dr. E. D. Ferguson's experience had been that in- flammation in the neighborhood of the caput coli usually ended in resolution, but sometimes operative interference had been necessary. His only two cases of death had been where the patients refused an operation. Do not spend much time searching for the appendix. An im-

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