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ness. There was then great swelling in the region of the left tonsil. There was no fever, and but little pain, except on swallowing. The patient had expectorated a little blood mingled with pus. The treatment consisted simply of cataplasms and cold drinks. The hemorrhag_e increased in amount and the patient died on the follow- ing day. On autopsy an abscess cavity was found in the left tonsil, and at the bottom of the deep cavity, filled with clotted blood, was the internal maxillary artery, its walls thinned and ulcerated. The carotid and other ve.ssels were normal. It would seem that local pressure, had it been employed, might have checked the hemor- rhage in this case. The second case is that reported by ^'ergely■ in 1886. A man, thirty-four years of age, was taken sick on July 26th, and entered the hospital on the 30th. The pharynx, palate, and faucial pillars were intensely red. On the left side there was swelling of the soft palate and an- terior pillar, and projection of the tonsil. There was great resistance everywhere to the finger, no fluctuating point could be felt, nor any pulsation. The pain and swelling extended from the back of the throat to the angle of the jaw, and later to the mastoid region and below the hyoid. Buy Lamictal Online The patient was pale and prostrated. Surgical treatment was deferred for the development of fluctuation. On July 31st the symptoms were worse, but there were still no signs of pointing of pus. On August ist the condition was the same. The tonsil and adjacent parts were of a dark red color, ^'ergely was about to puncture the tonsil Lamictal Rashes when the patient showed him a little expectoration of mingled pus and Mood. The operation was then again deferred to the next day, but in the afternoon the patient died with a sudden pro- fuse hemorrhage. On autopsy no suppuration was found in the tonsil or pillars, but behind, in a little retro ton- sillar pocket, were some large black clots and bits of gen. de The'r., 1885, vol. .\Iviii., p. 517. Weinlechner : Wiener Med. Blatter, 1885, vol. viii., p. 1623. Moizard : Jour, de Med. et de Chir. prat,, 1886, vol. Iviii., p. 347. Postemski : Gaz. de Med. di Roma, 1887, Feb. 15. J. N Hall : Boston Medical and Surgical Journal, 1887, vol. cxvii., p. 604. Murphy: Loc. cit. Dunn: Univ. Med. Mag., 1890 and 1891, vol. iii., p. 455. Loc. cit. - Loc. cit. 552 MEDICAL RECORD. [October 28, 1893 necrotic cellular tissue. The internal carotid artery was cut in two about two centimetres above its origin. The upper end of the vessel was not found. In this case, as in two others of our series, the opera- tion had been deferred for a day or a few hours and the surgeon thus escaped the charge of having precipitated the hemorrhage. But, on the other hand, had the incision been made early, without waiting for Purchase Lamictal signs of fluctuation, the ulceration of the artery might have been prevented and the life Buy Lamictal of the patient saved. In seeking an explanation of the Buy Cheap Lamictal spontaneous rupture of the carotid artery in phlegmonous inflammation of the throat, it has been suggested that there must be present some general constitutional dyscrasia, or perhaps an im- paired state of the walls of the vessel, due to previous attacks of inflammation in its neighborhood. In only four of our cases was there any such cause for the acci- dent. Two patients were suffering from scarlet fever when the throat affection began, and a third was said to be subject to abscess of the tonsil. In Duke's case the blow on the head was undoubtedly a most important etiological factor. Vergely ' believes that the vicinity of the air passages is the great local exciting cause of the accident. Micro- organisms and foul gases are constantly inspired and ex- pired and may easily give a septic character to the pus in the neighborhood. According to Verneuil,'' the outer arterial coat becomes thickened in an abcess cavity, if neither fever nor septicaemia occurs. But if these com- plications arise, the protecting cover disappears and the artery is denuded. In angina the pus and gases con- fined in the pharyngo-maxillary space, kill the arterial wall before compensatory hypertrophy has time to take place. Probably the septic character of the Lamictal Use pus com- bined with Rash Lamictal pressure are the important agents in eroding the artery. Hence the supreme importance of relieving the tension of the parts even if suppuration has not yet taken place. Bosworth " tells us that we may expect the formation of pus by the end of the second or on the third day. In protracted cases, Purchase Lamictal Online lasting ten days or two weeks, suppuration is not delayed, but the abscess is probably deeply seated in dense tissue and approaches the surface slowly. I have already Cheap Lamictal said that the hemorrhage occurred in three of our cases on the third day, so that the accident could hardly have been anticipated. It should be noted that in two of these cases scarlet fever had been present for a week or more, which may account for the rapid yielding of the arterial walls. It is rather remarkable that the great majority of the patients were men. The sex is noted in sixteen cases, and of these twelve were male, one was female, and three were very young children. This preponderance of the male sex naturally suggests syphilis as an etiological fac- tor, but this disease is not mentioned by any observer. Conclusions. — i. In, the inflammatory process is usually situated without, and not within, the tonsil. 2. If pus forms it should be evacuated at the earliest possible moment. 3. Unless there are signs of pointing else- where, the incision should be made through the soft pal- ate directly backward. 4. If the tension of the parts is very great, the incision is indicated, even though pus has not formed. 5. If ordinary surgical care is exercised, there is no danger of wounding the internal carotid artery. 6. In cases of deep-seated inflammation, in which the pus comes to the surface slowly, erosion of the arteries in the neighborhood may take place. In such cases, therefore, we Lamotrigine Lamictal must be ready to deal with arterial hemorrhage at the moment the abscess discharges into the pharynx. Senile Vesical Irritation is often juomptly relieved by a ten grain dose of phenacetin at bedtime. — Green. ' Loc. cit. ' Bui. de Soc. deChir., ' Loc. ciL, p. 116. . P- 74°. MODIFIED " MILK— BY PRESCRIPTION- MILK LABORATORIES, ETC." Lamictal Online By W. p. NORTHRUP, M.D., This meeting is in the interests of fresh and clean milk for infants and invalids. Reports say our present milk supply is a mixture twenty-four and thirty-six hours old. The question is, can fresh Lamictal Mg and uncontaminated milk be obtained ; how, and where, may it be obtained ? Lastly, concerning an improved form of milk feeding for infants. The topic which has been assigned to me is, " Modified Milk by Prescription — Laboratories," etc. As there are but two all-around illustrations of my topic in the world, and but one in New York, I can best compass the ground by speaking of this plant, and what it seems to be able to do for us toward meeting our demands. A milk laboratory must control its primal milk .supply. I shall, therefore, bring this paper into harmony with the intent of the meet- ing by beginning with the dairy. Laboratory, prescrip- tion writing, and general indications will follow. I may say briefly, for those not familiar with the work of this Section, that we are Order Lamictal Online speaking of a milk laboratory re- cently started in New York, a duplicate of that in Boston. Its function is, having taken fresh cow's milk, to change its relative proportions of fat, sugar, and albuminoids to the relative proportions of the same found in good Lamictal Discontinuation average breast milk. This prepares the way for rational substitute feeding and such other modifications as invalids may require. Cows. — Animals Lamictal Xr of quiet temperament are .selected from native good grade stock, avoiding the Order Lamictal strictly butter breeds — inexpensive, good milkers, such as tend to get fat when undisturbed. These are carefully inspected every month l)y a veterinary surgeon, and any cow which is not entirely well is thrown out. The stables have water-tight floors, manure is carried to a distance, certain amount of breathing space secured to each animal, etc. Bedding for the cows is white sand four inches deep. It has been necessary to abandon the use of straw ; some bacterial growth occasionally got from it into the milk, causing an unpleasant taste. It is considered desirable for infant food to use a diffi- cult-creaming milk, i.e., a milk from which the cream rises slowly — the fat globules being small, and remaining long in emulsion. The feeding of the cows is such as will secure alkaline milk as near as possible. But what is considered more important is to procure the milk of a cow in her normal condition, not over-stimulated. What is to the dairy- man's interest in quantity of milk is considered opposed to the interest of milk for infant feeding. On the other hand, a strictly butter cow is not considered a baby's cow. The baby's cow /tar excellence is the cow best calculated to raise her own calf upon her own milk. Modifying Milk. — On its arrival at the laboratory the milk is less (at present time) than two hours old. Im- mediately it was drawn, the glass jars into which it was drawn were ])ut into an ice and water mixture, and cooled to 45° F. In its journey to New York it rises two degrees, but still remains below 50° F., a safe limit against rapid bacterial growth — so found by experience. The first act of modifying is to pass the milk through a centrifugal machine and whirl out the cream at the high- est and innermost level, the separated milk next, and leave against the peripheral wall any impurities that may have fallen into the milk, such as hair or particles of dust. The speed of the centrifugal cream machine is about 4,400, the lowest that will "separate." A low speed is thought to break the fat-globules less — almost none. We have, then : i , cream sixteen Generic Lamictal per cent, fat (stable percentage); 2, milk free of fat ; 3, against the wall any impurities. These are removed at intervals and the ma- chine cleansed. The freshness and cleanness of milk has come to mean ' Read before the Paediatric Section of Academy of Medicine at a so-called " Milk Meeting," October 12th. October 28, 1893] MEDICAL RECORD. Lamictal Buy 553 more and more to baby feeders, and will Lamictal Lamotrigine be touched upon by other speakers more fully. Suffice it to say that for '• modifying," milk must be fresh. The following is the history of certain milk coming daily into New York from a farm in Westchester County. At 4.30 A.M. milking begins; at 8.15 the milk is deliv- ered at the milk laboratory, having in that time been in an ice-and-water mixture an hour, and upon the cars 40 minutes. Adams Express Company gets from the farm

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