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fatigue, grief, discontent, homesickness, and unhappi- ness from whatever source. The farmaceutica viagra doping female writer cited a number of cases in which these factors had played the decisive part in the progress made by the natient. Worry in any shape might do much harm. farmaceutica viagra doping female In looking over the his- tories of 740 cases of tuberculosis treated during the past fifteen years, 129 showed reason for believing that some form of nervous depression was at least an im- portant causative factor, and he felt sure that it was much more commonly a cause than these figures indi- cated because some of the earlier histories gave no data on this point. The prolonged physical and mental rest, kann man viagra in der apotheke kaufen and the limitations necessarily imposed during a "cure" sometimes became so irksome as to be a real detriment to the patient. In such cases finding out and making available suitable mental diversion might be the means of changing failure into success. These considerations showed the need of personally taking case histories and getting into close confidence with the patient, in order that one might know all the factors in their lives which had to do with their powers of resistance. They also emphasized the need of treating the patient from the standpoint of the individual. (See also p. 562.) Dr. J. N. Hall of Denver said the remark had been made in the paper that some patients did badly because they were not digesting their food. He had so often found than an associated appendicitis was the cause of failure to properly digest the necessary amount of food that he sometimes thought perhaps he had laid too much stress on this possibility. He thought at one time that the trouble was that these tuberculous patients had tuberculous appendicitis, but he had farmaceutica viagra doping female found that it was only ordinary appendicitis and such patients never did well until the apnendix was removed. In an ordinary case of tuberculosis complicated by appendicitis it was worth while taking the risk of the operation in order to get the improved digestion which usually followed the relief of the appendiceal condition. Dr. Philip King Brown of San Francisco said that it had been their experience at the Areauipa Sanatorium that about 10 per cent, of the patients had to have attention directed to the digestive function, and about five per cent, had to have the operation of appendec- tomy either considered or the appendix actually re- moved, and it was their practice to take as conserva- 584 MEDICAL RECORD. [Oct. 2, 1915 tive a position as possible. The operation of appen- dectomy since it could not be done under gas anesthesia did not present such a serious problem for the tuber- culous patient as formerly. In these tuberculous patients the condition of the teeth and tonsils should also be considered, and operation performed if re- quired. In only one instance had they found a tuber- culous appendix at operation. However, he believed that they should be conservative in reference to oper- ative intervention. Dr. \V. J. Barlow of Los Angeles pointed out farmaceutica viagra doping female that individualization which had been taken as the keynote of treatment by the author of the paper was much easier to carry out in the home than in a sanatorium. He had found that too much exercise on the part of a patient who should have been at rest might interfere with digestion, and that as soon as the patient took the proper amount of farmaceutica viagra doping female rest the digestion improved. As late as five years ago he had hesitated to operate for appendicitis on a patient suffering with tuberculosis, but he had found that these patients passed through the operation as well as a normal person. The psycho- logical factor in tuberculosis cases was always inter- esting, and he felt that it was very important in every case. Dr. John M. Swan of Rochester, N. Y., said the most important point in the paper was the emphasis placed on the importance of securing a nroper mental attitude on the part of the patient, and this was not only true of tuberculosis but of every other disease. The physician was apt to expend so much energy in reaching a diagnosis in a case of tuberculosis that he had little energy left to work out the details of the case. It was the duty of the physician to help the patient adapt himself to circumstances, and this often required considerable psychical treatment. Col. George E. Bushnell, U. S. A., of Fort Bayard, N. M., said it was not so easy to individualize in treat- ing tuberculous patients in the army farmaceutica viagra doping female as in civil life. Their ideal in reference to diet need not necessarily be to get as much weight as possible but to get the patient into good condition so that he digested his food better, has perfect health and perfect metabolism. A patient might sometimes gain in weight and yet be doing badly. Dr. G. W. Holden, in closing the discussion, spoke further of the importance of the mental attitude of the patient and said it was frequently very difficult to con- trol parents and relative of the natient who persisted in relating or writing the family troubles, financial and otherwise, to the patient. The diet of the patient also required individualization; sometimes the proteins had to be cut down and sometimes the starches, but where there were a large number of patients it was sometimes difficult to carry out the details of the diet. Coccoidal Granuloma. — Dr. Philip King Brown pre- sented this patient who had scalp lesions due to the coccoidal organism. The other symptoms and signs which the patient exhibited were those typical of pulmonary tuberculosis. Dr. Brown said the condition was very rare in California, though Dr. Dixon had a report of nine cases which he would present at the Pan American Congress. The lesions were somewhat like those of pellagra. It had been said that no case of coccoidal infection had been known to recover with the exception of one in which ankle was involved and