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The Necessity of Close Inspection in Head In- juries. — By Dr. purchase lisinopril R. H Lewis, of Macomb. The au- thor emphasized the importance of investigating every case which comes under observation. Sufficient time has now elapsed since the inauguration of operative procedures upon the cranium and lisinopril buy brain for the cure of various mental and physical defects to allow us to judge somewhat correctly of their merits, and in look- ing over the reports of cases with subsequent histories in the hands of the most competent operators, the speaker was astonished to find so small a percentage of actual cures resulting from what at first seemed bril- liant and promising methods. After relating an in- teresting case of depressed fracture of the skull, which the author had treated successfully, he drew the fol- lowing conclusions: 1. All scalp wounds will bear close inspection. 2. The troubles resulting from pressure on the brain should be removed so soon as manifest. 3. This work should be done by the general practi- tioner in the rural districts, as well as by the skilled surgeons in the city. Craniotomy on the Dead Child.— Dr. Joseph B. De Lee, of Chicago, read a paper with this title, in which he gave the following indications for crani- otomy : 1, All cases in lisinopril 5 which the child is dead give indi- cation for the termination of labor. This operation should be done instead of using the forceps, when the maternal soft parts are unprepared for rapid lisinopril 10 delivery. Such cases are eclampsia, placenta previa, premature detachment of the normally implanted placenta, pro- lapse of the cord, with danger to the mother from any cause. In short, the forceps should not be applied on a dead child. The only exception the speaker would make to this rule was the case of a multipara, with the head low down and the soft parts well prepared, 2, Cases of contracted pelvis when the conjugata vera is not smaller than two and one-half inches. To do a hard version extraction, or extraction by forceps, or a Caisarean section, is not justifiable when the child is dead, 3, In neglected transverse presentation embryotomy should be done. The thought of a version should not be entertained lisinopril 20 for a moment. Cleanliness in Obstetrics. — Dr. Emm.\ B. Stand- ley, of Alexis, contributed this paper. The first lisinopril 5 mg step in cleanliness in obstetrics was for the physician to be clean himself when called upon to lisinopril 40 mg attend a woman in confinement. Her plan has always been to allow the mother to rest for a little time after delivery until the babe is attended to; then a bowl filled with warm wa- ter is brought and a disinfectant added, and the pu- dendum thoroughly cleansed, care being taken not to expose the patient. Another help to cleanliness in obstetrics was the rectal enema of warm water that the bowels might be thoroughly moved. This has a re- laxing effect upon the sphincter ani muscle and peri- neum, and prepares the way for advance of the child far better than if the physician has a loaded rectum to contend with. Hydrotherapy in the Management of High Tem- perature in Typhoid Fever. — By Dr, Cteoroe G, Cr.aii;, of Rock Island. He enumerated the methods generally used for applying hydrotherapy in the treat- ment of typhoid fever. As with any other remedy, judg- ment must be exercised in the selection of the mode and the manner of administering it in each individual case, bearing in mind that statistics prove cheap lisinopril that the nearer the exact teclinique of order lisinopril Brand is and has been followed the better the results. In all cases the phy- sician could not let his views be known, but in hos- pital practice particularly, and in private practice when possible, the author believes that we lisinopril 20mg should adopt hydrotherapy as a whole or in part. Dr. O. B. Will, of Peoria, read a paper entitled "Some Obser\-ations Respecting the Etiology of Ecto- pic Pregnancy."' Surgery of the Gasserian Ganglion. — Dr, J. B. Murphy, of Chicago, followed with a demonstration of the surgery of the Gasserian ganglion, and reported cases. He confined himself almost exclusively to the technique of the more recent operation, after review- ing the lisinopril 10 mg results of previous operations for the removal of the ganglion. Internal medication and anodynes had absolutely failed to permanently relieve the intract- July 4, 1S96] MEDICAL RECORD. 29 able neuralgias of the face. Reference was made to the methods advised and advocated by Rose, Horsley, Andrews, and others, for the removal of the ganglion. Dr. Murphy then described in detail and illustrated a slightly modified technique of the Frank Hartley oper- ation. He said there had been forty-seven cases col- lected up to date, w ith only two deaths. One of the patients died shortly after the operation from shock. The other death was presumably due to the advanced age of the patient. Dr. Joseph B. Bacon, of Chicago, contributed an interesting paper on Dermoid Cysts as a Cause of Fistula in Ano All of the cases were of blind internal fistulas that were sent to lisinopril 10mg his clinic for operation, the fistula being con- nected with small cysts. The patients attributed their ailment to chronic diarrhcea, ulcer of the bowel, or piles, and could give only an indefinite history of re- peated attacks of pain. The first case was that of a practitioner of medicine who came to the Post-Graduate Hospital, November, 1895, to be treated for painful ulcer of the anus. He was a w«ll-deveIoped, muscular man ; weight, one hun- dred and eighty pounds. He gave an indefinite history of painful defecation, spasm of sphincter muscles, and discharge of pus from bowel, that extended back over a period of several years. After patient was anresthetized and the sphincters divulsed, an anal ulcer with every appearance of an ordinary mechanical tear of the mu- cous membrane was noticed on lisinopril hctz 12.5 mg the posterior median line of the anal canal between the. internal and exter- nal sphincters. The ulcer was covered by old granu- lations. After removing the granulation tissue with a curette, a lisinopril 12.5 fistulous tract was found leading into a small sac, filled with granulation tissue, pus, and a bunch of fine blond hair. The sac was found to lie behind the anus and veiy near the skin. The external sphincter w-as severed in the posterior median line and the sac laid online lisinopril open and curetted and converted into an open woimd. The wound was packed with iodoform gauze and daily irrigated with boric-acid solutions and repacked. The patient made a perfect recovery in three weeks. The author reported three other cases, and lisinopril 12.5 mg stated that he had done so because there was a limited amount of literature upon the subject. The cases were interesting in that they afforded a favora- ble prognosis in a certain per cent, of fistula in ano, a very important point for those interested in life in- surance. The very large percentage of fistulas of a tuberculous origin may prevent patients suft'ering from fistulffi in ano receiving insurance. Yet a more careful consideraton of each case and its history would determine that possibly some of them are due to dermoids, and thus all anxiety for the patient's gen- eral infection from tuberculosis would be removed from doubt. Metatarsalgia, with a Report of Three Cases. — This paper was read by Dr. A. E. H.\lste.\d, of Chi- cago. After dealing with the subject in an exhaustive manner, the author concludes: T. That what is known as metatarsalgia is not in the beginning a distinct pathologic entity, but rather an early symptom of static flat foot. In cases of long-standing irritation of the plantar nerves by pres- sure from flattening of the transverse metatarsal arch may cause an inflammation of the nerve, or even in some cases the development of a neuro-fibroma. 2. That most of these cases can be permanently cured by following the treatment usually employed in beginning flat foot — e.g., systematic massage, gT,-mnas- tics, and the use of properly fitted shoes, and in some cases the application of a metallic brace to the sole of the foot. 3. In cases of long standing, where there is well- marked pathologic change in one or more of the branches of the plantar nerves, resection of the nerve should be performed. The more radical operations, such as resection of the metatarso-phalangeal joint or amputation of the toe, are not indicated. Cholelithiasis : A Plea for Operative Treatment. — By Dr. E. Mammer, of Bloomington. All cases which are not promptly relieved by the passage of small stones, or by therapeutic measures effectively and judiciously employed, at once furnish true indications for resort to cholecystenterostomy. The operation can be safely done and will be success- ful when calculi are in the gall bladder only; when they are in the gall bladder and in the c\stic duct; and when they are in the ductus communis choledo- chus, and can be removed, or when, even if left there, the bile will find a free passage by the new channel. Indications for operation in such as the above may be detemiined by carefully weighing all symptoms hctz 12.5 lisinopril and a thorough study of them in all their relations. The author reported two lisinopril hctz 20 cases in which he had operated successfully. Vaginal Section for the Cure of Retroversion of the Uterus was the title of a paper read by Dr. Henry T. ByFORn, of Chicago, in which the author described the technique of the method which he had employed as follows: The vulva and vagina are thoroughly scrubbed with softsoap, then with strong alcohol and with a I to 2,000 solution of bichloride of niercur}-. The uterus is dilated and curetted, and disinfected with mild or strong solutions, according to the require- ments of the case. This preparation is necessar)' to prevent the infection of the connective tissue and buried ligatures. A transverse incision, a trifle over an inch long, is made in the vaginal wall just in front of the cervix and the bladder separated' from the uterus by the fin- ger as far up as the peritoneal reflection. Then a longitudinal vaginal incision about two inches long is made in the median line from the neck of the bladder to the middle of the transverse incision. The bladder is separated from the vagina for a short distance on either side of the incision to give room for manipula- tion. The peritoneum is then torn across between the uterus and bladder, an intraperitoneal pelvic examina- tion is made, adhesions are separated, and such parts are treated or removed as may so require. The blad- der peritoneum is then seized by forceps and drawn down by successive grips until that which belongs be- hind the pubes can be seen. Two chromicized catgut threads are introduced about one inch apart through this portion of the peritoneum and subperitoneal tis- sue as 20 mg lisinopril high as possible. Then the anterior surface of the uterus is grasped with tenaculum forceps and the fundus pulled into the vaginal wound and attached to the bladder by means of the above-mentioned catgut threads. The finger is now hooked over the left round ligament, which lies beside the vaginal wound: a loop of the ligament is drawn into sight, grasped by forceps, and pulled down until the inguinal end is taut. A catgut suture is put through it as far from the uterine end as possible and is made to attach it to the uterus

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