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there was a standing order throughout the medical wards that the resident surgeon as well as the i-esident physician should how to make homemade viagra be called whenever a typhoid patient had pain in his abdomen. In this series there were seven perforations disclosed by laparotomy with three recoveries; there were a few instances of operation where no perforation was found. There was not a single case of perforation that went unoperated upon and the longest time which elapsed between perforation and operation w^as a little over twenty-four hours. Those cases which went to twenty or twenty-four hours were accompanied by hemorrhage and how to make homemade viagra for this reason the perforation was obscured. He called attention to the fact that in those days there was usually too much interference and that he believed that when operation was necessary as little as possible should be done. Dr. H. B. Delatour of Brooklyn reported the results in how to make homemade viagra nine cases of operation in typhoid which had come under his personal care; five of these patients recov- ered. He also reported a operated upon for acute cholecystitis, for which no cause could be found at the operation but from which a culture taken from the gall- bladder showed the typhoid bacilli, and the history sub- sequently obtained showed that the patient had had typhoid fever seven years previou.slv. In regard to an- aviagra nendicitis occurring during typhoid, he stated that in his experience, where the appendix became involved aviagra in the early stages of typhoid it was seldom perfoiati'd. but where it became involved in the later stages, it was more apt to go on to perforation. Dr. M. L. Harris of Chicago called attention to the fact that in cases of typhoid perforation the patient was suff'ering from an acute general infection as well as from an acute peritonitis, and recognizing this fact in his last two operative cases, he opened the abdomen as quickly as possible under local anesthesia, closed the perforation, left the abdominal cavity wide open, and placed the patient in a permanent bath, with the water in the tub and abdomen free to each other; both patients recovered. Dr. John Bapst Blake of Boston emphasized strongly that in very sick cases the perforation should not be closed but should be left open, thus practically forming an enterostomy; this would diminish the gen- eral toxicity, decrease the intestinal distention, and compel abdominal aviagra drainage; it would also save a little time in the operation. Dr. K. A. J. Mackenzie of Portland, Ore., reported a case of supposed typhoid perforation in a child of 8 years in which it was found that enlarged lymph nodes were responsible for the symptoms. These sur- rounded the appendix and together with that organ were removed. Three months later symptoms of acute obstruction developed and operation revealed an ileal intussusception which was relieved. During the last three years the patient developed symptoms of chronic intestinal obstruction and operation revealed a loop of ileum adherent by a how to make homemade viagra thick band to the anterior abdomi- nal wall; this band was divided and the patient recov- ei'ed. The interesting point in this case was the aviagra fact that at the original operation the crisis took place im- mediately upon removal of the large typhoid lymph nodes. The speaker stated that he aviagra had operated in four cases of typhoid perforation with one recovery. Dr. A. J. OSCHNER of Chicago called attention to the possibility of reinfection with typhoid bacilli from the gall-bladder, and reported a case. He recommended that in any case of acute cholecystitis during an attack of typhoid fever, good results would be obtained by placing the patient on exclusive rectal feeding, giving an ounce of concentrated predigested food dissolved in three ounces of physiological salt solution every four hours and the administration of large quantities of salt solution by proctoclysis. Dr. Dean Lewis of Chicago reported a case somewhat siiTiilar to that mentioned lay Dr. Mackenzie, in which the symptoms of acute appendicitis were found to be due to enlarged ileocecal lymph nodes. In this case the appendix was removed but the lymph nodes were left, and a blood culture made the following day showed the paratyphoid organism. In this ease also the crisis im- mediately followed operative interference. He referred to another case in which the symptoms were supposed to be due to the appendix, but removal of this organ was followed by a recurrence of the attack, resembling a perforation of a duodenal ulcer or an acute cho- lecystitis. A blood culture showed the paratyphoid organism. The patient was sick for seven weeks with paratyphoid, recovered, and then had several attacks simulating gallstone colic, but these attacks were ac- companied by little or no temperature and no iaundice A cholecystotomy was performed, the gall-bladder found white and thickened, no gallstones were found, and the bile appeared normal, but the paratyphoid orsranism was grown from a culture taken from the bile. Follow- ing drainage of the gall-bladder. Dr. Lewis said, the at- tacks had disappeared and the organism disappeared from the stools. Dr. J. EwiNG Mears of Philadelphia stated that in 1888 he presented a paper before the American Surgi- cal Association entitled "The Propriety of Surgical In- terference in Perforating Typhoid Fever Ulcer," and at that time only four cases were recorded in the medi- cal literature, in all of which a fatal result had oc- curred. In this paper of twenty-five years ago attention was called to the value of making aviagra an artificial anus, to be relieved later by an operation, should the patient survive. The claims for this procedure were that it facilitated the free escape of fecal contents and gas. thereby adding to the quietude of the patient and secur- ing rest to the intestines. He advocated that in all cases of operation laparotomy with the production of an artificial anus should be the method employed, and under the additional knowledge gained during the in- tervening years, he still held this opinion. Dr. F. W. Parham of New Orleans reported a case of typhoid fever in a boy of eleven with interesting and 424