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attended with a general mortality, and that indeed they are sometimes directly homicidal." The prime object in the treatment of appendicitis is to prevent the usual cause of death, viz., perfora- tion. Of course the question would devolve itself into, "Would the danger of removing the appendix during this period be ,greater than the risk of the appendix perforating?" I might go on and cite opinions and instances by famous authors every- where, but it would take up too much time. I onl> wish to say in conclusion that a conservative, close observation of these cases in a moderate surgical practice in this locality for fifteen years leads me to state that the intermediary period is the time when a surgeon should withhold his hand. I repeat : "To Operate or Not to Operate ?" To operate in the primary period, in buy suprax the abscess period, and suprax mg in the interval period. Not to operate in the intennediary period, when there is great distention and hi,gh fever, because the risk of perforation of the appendix is less than the risk of operation at this period. I believe and I hope that everyone who reads these conclusions carefully and ponders over them and ob- serves the results, not only in his own practice, but in that of others, will be convinced of their truth, so that the publication of them will, I trust, be con- sidered at least a slight attempt to establish land- marks and guideposts in the management of appen- dicitis. Regarding the two deaths above referred to, fol- lowing operation, one occurred in the practice of one of my friends ; it was the case of a child that was operated on in the abscess period and died some two weeks after operation. The case of death following operation in my own practice was as fol- lows: Miss O., age 23, had had previous attacks of appendicitis. I was called in consultation with Dr. Heles to see her on the third day of the disease. Her suprax antibiotics temperature was 100° and her pulse 90; no dis- tention, but extreme tenderness in the McBurney region. She had vomited the day previous and on the morning I saw her. Operation was advised and accepted, and she was removed to the Mercy Hospi- tal in the afternoon. The operation was performed at 3 P.M. On opening the abdomen, the apnendix. very greatly enlarged, imbedded in a mass of adhe- sions, was enucleated with considerable difficulty, but finally removed without perforating. It was very much enlarged and contained pus and a concre- tion as large as a kidney bean. The concretion had acted as a ball valve, allowing the contents to pass from the bowel into the appendix, but preventing their return. The constant pressure had so increased the size of the appendix as to produce almost ulcer- ation at the points of its juncture with the cecum. The operation was quickly done, without any acci- dent, and the wound closed as usual. The patient re- acted well and I left for St. Louis that evening. Dr. Heles furnished me the remaining history suprax cefixime of the case, which suprax 100 was as follows: "The patient reacted well, fever dropped, pulse became normal in a day or two. and everything went along to a most speedy convalescence. The stitches were removed on the tenth day. On the evening of the fourteenth day, after entertaining her friends for an hour or two in Oct. 6, 1906] MEDICAL RECORD. 537 the evening and tlismissing them with a jjood-night, saying that she was going home in the morning. the> left. She suprax 400 mg tablet requested the suprax cefixime tablets nurse to turn down the light, so that she could get some sleep, as she was going suprax 400mg home in the morning. The nurse did as she was re- quested and left the room. In about five minutes the bell rang, and when the nurse entered the room Miss Q. sat up in bed and said, 'Open the window : I am smothering,' and fell dead upon her pillow." On talking with some of her friends afterwanl I learned that she had had, two years previous, while attending a picnic, a fainting spell, from which she was revived with great difficulty. From the history and outcome of this case, which, of course, had buy suprax online nothing to do with the operation, I am inclined to think that death was caused by probable heart clot. .^s stated, this is the case in which I had death following operation for appendicitis ; it shows, how- ever, that no matter how careful or accurate we may antibiotic suprax try to be, work by human hands will never at- tain perfection. Spastic Constipation. — T. W. Stumm, in his paper oil this subject, declares that treatment is the most important thing in these cases. The physician must remember that he has to deal with an irritative condition in the large intestine, and that the ordinary means resorted to in reliev- ing atonic constipation will only aggravate it and make it worse. The patients usually try all the cathartics known to them, and find that they only make the condition worse. The diet must be selected with great care. Patients suf- fering with spastic constipation should be given foods that are bland and non-irritating. Such a diet, rich in cellulose, as is ordered in atonic constipation, will only aggravate spastic constipation, by increasing the irritation in the in- testine. Pickles, cabbage, turnips, cucumbers, pork, pickled meats, goose, strong coffee, and tea should be avoided Fruit may be allowed, but would much better be cooked than raw. Food that will excite peristalsis through a chem- ical action rather than a suprax generation mechanical one should be selected. In contradistinction to atonic constipation, the patients do much better with only moderate exercise. Sometimes rest in bed for generic suprax two or three weeks will do much good. Warm baths and hot applications to the abdomen are beneficial in causing a relaxation of the spasm. The baths should l>e taken just before going to bed, and heat in some form, ap- plied while in bed, is helpful. During the day the abdomen should be well protected with woolen cloths. Medicinal treatment in such cases is not satisfactory. Cathartics in all forms should be avoided. Belladonna or opium acts very well in relieving the spasm, but the best therapeutic results are obtained through the injection of olive oil. or what is equally as good, cottonseed oil. This is used at first every night, later every second night, and then once or twice a week, as it is needed. After a time it may be en- tirely discontinued. The action of the oil is probably three- fold ; it lubricates the mucosa of the intestine : it softens tho intestinal contents ; it further aids chemically in splitting fatty acids. The last action is probably the one that causes an increased peristalsis through chemical excitability. The writer adds that, in order to secure results, the oil must be properly injected. It should be given order suprax before going to bed, and retained until morning. The ordinary individual will retain a pint. The patient should suprax injection lie on the right side, the left limb extended, the right flexed at the knee and placed in front and over the extended left one. The oil, at a temperature of 100° F., is allowed to run slowly into the intestine through a moderate-sized rectal tube passed seven or eight inches into the rectum. The patient should then remain perfectly quiet. If the hyperacidity is annoying, it may be necessary to order a little magnesia for a time, but an excess of fat in the suprax cefixime 400 mg diet will usually overcome any acidity. Small doses of Carlsbad salts, but not enough to act as a laxative, may be used instead of the magnesia or the fatty diet, if the physician does not care to employ these. It is sometimes necessary to suprax injections employ bromides if marked nervous symptoms are present. Such means as are outlined here usually secure good and lasting results. Electricity, massage, violent exercise, cold baths, and other measures employed in atonic constipation should not be used in the treatment of spastic constipation. — The St. Paul MrdirnI JnuriMl Ante- and Post-Operative Treatment of Cancer of the Breast. — George C. Johnston says that the changes tak- ing place in carcinomatous tissue when exposed to therapeutic doses of Roentgen rays, consist of a break- ing down of the islands of diseased cells, beginning and most pronounced in the rapidly-growing periphery. .■\ peculiar endarteritis of an obliterating type attacks the blood-vessels, which are surrounded by masses of small cells. This degeneration is apparent in even the deepest part of the tumor. A dosage can be formulated and administered strong enough to de- stroy the pathological tissue, but sparing the normal, in addition to the change in the tumors and the blood- vessels, a peculiar action on the lymphatics, both vessels and glands, is noted. The former are, as it were, sclerosed. The glands are small, hard, fibroid masses. If there were no other factor to be considered, radiation might be re- garded as an agent fulfilling every indication to be desired in the treatment of this disease. Vet the fact has to be accepted that the use of the ray alone in the treatment of carcinoma is jusified in but few cases. As of old. the mainstay is careful complete surgical extirpation in operable cases. On the other hand, operation alone cannot boast of a remarkable percentage of cures. The writer describes a course of radiation which he believes will accomplish the desired prophylactic result in the majority of cases. He is convinced that cases of extensive carcinoma may be taken in charge, rayed, operated upon, and by a continued post-operative treatment freed from carcinoma. Successful work demands the intelligent cooperation of the surgeon and the radiologist. Much can be accomplished when these two work together with a full knowledge of the limitations of their art. The ;r-ray must not break down more tissue than the patient can successfully eliminate, and the knife must not remove more tissue than is abso- lutely necessary. The writer states that a large percentage of successful results need not be expected, but he believes that failure should stimulate repeated en- deavors. He holds that the cure of one ordinarily hopeless case is a greater victory purchase suprax than a long series of successful results in ordinary, priman,- cases. — Archives suprax tablets of Physio- logical Thcrafy Fat Indigestion from a Mother's Milk. — W. P. North- rup gives the history of this case in which a mother, anxious to nurse her child, fell into misfortune through trying to follow the conflicting advice of several phy- sicians. If any one efficient practitioner had had the sole responsibility of the case, all mishaps would have been prevented. .'\n attack of tonsillitis on the part of the mother apparently disturbed the baby's digestion somewhat. The second attack with its consequent anemia wholly upset it. An excess of fat was found in the mother's milk, apparently produced by forced feed- ing, including a quart of milk daily, lack of exercise, indoor living, and two attacks of tonsillitis. This excess of fat brought about in the infant ileocolitis with the symptoms of diarrhea (no vomiting), with frothy, brownish to olive-green, offensive passages, containing an excessive suprax antibiotic for children amount of mucus in tenacious masses, colic, sleeplessness, and loss of weight. The fat in the milk was lowered by diet and driving in the open air, from 8.98 per cent, to 4.90 per cent. The infant became sus- ceptible to the presence of the least trace of milk in her food and could not digest it for a time. Castor oil and barley water were given and irrigations were re- sorted to. The child recovered. The writer states that in another case of this kind he would take the baby from the breast at once. — Archives of Pediatrics. 538 MEDICAL RECORD. [Oct. 6, 1906 Medical Record. A Weekly Journal of Medicine and Surgeij. THOMAS L. STEDMAN, A.M., M.D., Editor.

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