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President, get doxycycline Robert W. Taylor, Joseph D. Bryant, W. P. Northrup; Trustee, A. Jacobi, Edward S. Peck, W. H. Katzenbach ; Committee on Admission, John S. Warren, Andrew F. Currier ; Committee on Library, William Gilman Thomson, John W. Brannan, S. T. Armstrong. Amendments to the By-laws. — The following amend- ments to the by laws were adopted : i . No section is authorized to institute any procedure that is of a public character without first submitting the project to the con- sideration and approval of the Academy. 2. Special meetings may be called at any time by the chairman of a section upon the requisition in writing of ten fellows assigned to that section. The announcements of such special meetings are to be printed and mailed to each fellow of the Academy, at the expense of the Academy. 3. An amendment essentially as follows : A resolution in- volving new business, or pertaining to a subject that is not germane to the matter announced for consideration at an Academy meeting, must be mailed separately to each member at least one week in advance of the meet- ing. Bureau of Trained Nurses. — At the recommendation of the Council resolutions were adopted providing for the establishment of a bureau of trained nurses in the Academy building, the President being empowered to appoint a doxycycline order committee of how to buy doxycycline five to carry out doxycycline to buy the purport of the resolu- tions. Intestinal Anastomosis. — The discussion for the even- ing was in charge of the Surgical Section, the Chairman of which. Dr. Joseph D. Bryant, occupied a seat by the President on the platform. Dr. J. B. Murphy, of Chicago, read the paper, in which special attention was given to the following points: i. The means of pro- ducing union of divided intestinal tissues; 2, the com- parative value of end to end and lateral intestinal ap- proximation ; 3, cholecystenterostomy ; 4, post- operative narrowing of the interintestinal communications; 5, the influence of time employed in operation, as bearing on consequent shock and peritonitis. The discussion which followed was participated in by Drs. W. W. Keen, R. F. Weir, Robert Abbe, and B. F. Curtis. Danger of Obstruction by the Button and of Cicatricial Constriction. — Dr. W. W. Keen, of Philadelphia, said he had performed an anastomosis on the digestive tract in but a limited number of cases, eight all told ; four cases of gastro enterostomy, four of intestinal anastomosis proper. Of the cases of gastro-enterostomy one died after twenty months ; one of exhaustion after the eleventh week ; the third was living at the end of eighteen months ; the fourtli 100 mg doxycycline at the end where to get doxycycline of a year. Of the four cases of in- testinal anastomosis one died at the end of forty-seven days, of a lesion independent of the operation. That was the only rase in which he had used Murphy's button. The second case died the eleventh day after the operation, of exhaustion. The third was believed to be still living at the end of a year. The fourth died within twenty-four hours after the operation for resection of the colon and lateral anastomosis. With his present experience, he thought that in a similar case he would prefer to leave the carcinoma intact and do lateral anastomosis alone. The means which he had used had been, in one, Murphy's button ; in one, the segmented ring of Ashton and Baldy ; and in the others. Abbe's catgut rings. In intestinal anastomosis there were four requisites, whatever the method used: i. Simplicity of execution ; 2, speed ; 3, security ; 4, that the opening shall be of suffi- cient calibre to obviate subsequent obstruction by cicatri- cial contraction. The methods had been named by the doxycycline where to buy author as follows: i, Suture alone; 2, suture and me- chanical means ; 3, mechanical means alone. The first requirement named he was sure had been fully- met by the button, which he regarded as one of the most ingenious mechanical appliances in the whole domain of surgery. With reference to speed, the button was again far in advance of any other means yet devised. He also thought it offered as secure, probably a more secure, meth- od than any other. In the case in which he had used the button he had depended on it alone, using no sutures, and it had secured perfect anastomosis. But what seemed to him would be likely to prove a fatal objection to it, was failure to establish an opening of sufficient size to be a guarantee against subsequent obstruction to the passage of the intestinal contents. In his own case, of which he exhibited the specimen, the subsequent narrowing had been considerable, and the explanation therefor in the disappearance how to get doxycycline of cedema, which he had understood the author to accept, could not have been the correct one, for the reason that the cedematous or diseased structure had been excised and union had been made between healthy portions of the gut. While the tendency in New York had been to discour- age the use of mechanical means doxycycline purchase online in intestinal anastomosis. Dr. Keen personally confessed to preference for such means over suturing alone, and especially for the mechan- ical means known as Abbe's rings. He felt, however, that that very large where can i buy doxycycline opening proposed by Abbe of late, say four inches in length, was needlessly large. Some of the objections which had been made to the button did not seem to him to be valid ones. For example, he did not think pressure necrosis would extend beyond the com- pressed tissue between the two halves of the button. As already stated, the most serious objection was danger of buy doxycycline subsequent contraction to such an extent that the intes- tinal contents could no longer pass. A lesser danger, one which he felt was real in spite of the fact that it had not yet occurred, was that of intestinal obstruction from failure of the button to pass through the intestine, espe- cially at the ileo-cEecal valve. One of the conditions in which the button would prove superior to all other means yet at our disposal, was in the operation of cholecystenterostomy, one of the most dif- ficult operations in abdominal surger)'. Inasmuch as nothing but fluids had to pass through the artificial open- ing, this was less likely to contract to the extent of pro- ducing subsequent occlusion, and a button of moderate size being used, it probably would pass successfully through the ileocsecal valve. Dr. R. F. Weir believed, as Dr. Keen had expressed himself, that the condition in which the button would prove to be especially useful was in making communica- tion between the gall-bladder and intestine after failure to do away with the. obstruction in the gall-passages. Like him, too, he had had some fear that the button might not get out of the intestine, notwithstanding the fact that this accident had not yet happened, according to the doxycycline cheap cases reported by Dr. Murphy. In gastro-intes- tinal union he thought mechanical means should be dis- carded. Experience in New York went to show that they had not afforded sufficient opening doxycycline mg between the in- testine and stomach. He had performed this operation, using Abbe's rings in one case, in one case sutures alone, taking not more than forty minutes from the time of opening the abdomen to closing it. As to the plugs or buttons shown for lateral anastomosis, he did not feel that one would be warranted in using them of so great size, lest they should fail subsequently to pass the ileo coecal valve. Yet it where can i get doxycycline was necessary, in his opinion, to make the doxycycline 100 opening three and a half to four inches long, in order to how can i get doxycycline obviate occlusion by cicatricial contraction. Dr. Weir showed a man who had been operated upon by a surgeon for hernia, who afterward developed an ab- dominal tumor supposed to be malignant, who was then subjected by a colleague to exploratory incision and union 79° MEDICAL RECORD. [December i6, 1893 of the caecum with the abdominal walls preparatory to further operation, should this prove necessary. His symp- toms becoming more severe, he passed into the hands of Dr. Weir, who explained to him the advantages of intes- tinal anastomosis over a temporary opening into the gut at the place where it had been attached to the ab- dominal walls, but told him also that anastomosis would be attended by greater danger. He chose anastomosis. Lateral union was made with an opening two inches and a half long, yet, in spite of the fact that only half a year had elapsed, there were now symptoms of recurring ob- struction, although it was impossible to say whether the obstruction was due to contraction of this large opening or to omental adhesions. The diagnosis of malignant growth had been made and abandoned, the tumor having diminished in size, pointing to subsidence of a simple in- tlammatory and edematous condition of the omentum at the site of the previous hernia. He also presented a specimen in a case of anastomosis between the stomach and intestine, illustrating the possi- bility of accident from use of mechanical means, catgut rings having been employed which twisted and led to fatal hemorrhage. He further showed Murphy's button on a specimen illustrating cholecystenterostomy. The application of the button to cases of rectal stricture, as described in the paper, he felt was a very valuable sug- gestion. A Needle and Thread Sufficient, and to be Had Everywhere. — Dr. Robert Abue doxycycline 100mg felt the untrustworthi- ness of statistics. They furnished but an imperfect basis on which to found impressions and guides. The paper contained statistics which he had not heard of, and left out others which were familiar in the East, especially with regard to the rings. Various devices had been brought forward for making ready anastomosis, but even the bone- plates, which at first promised so much, had been discarded because of serious objections. Any surgeon who was de.x- terous with the needle and thread, had a method always at hand which would serve him well in making intestinal anastomosis. The statistics of end to end anastomosis of the intestine had been based upon past imperfect methods, and therefore required revision. The reason why purchase doxycycline he had proposed so long an incision in lateral anastomosis was the fact that in four striking cases the necessity for this was demonstrated. In two he made the opening an inch and a half long, they died at the end of six months, of malignant disease, and in one the autopsy showed that the opening had contracted down to a quarter of an inch, and in the other to a small aperture which the tip of the little finger would hardly enter. The other cases were operated upon two years and a half ago, longer openings being made, and they were well to-day. The law of con- traction in cicatricial tissue should always be borne in mind when making anastomosis. When it came to the question of time. Murphy's but- ton was brilliant. It doxycycline online was apparently the climax of surgi- cal ingenuity. If it should prove that there was less danger of cicatricial contraction from the circular scar of end to end anastomosis, and this could be obtained with the button without danger of subsequent blocking of the gut, its use would prove a decided advance. It was, how- ever, in cholecystenterostomy that the button had so far won laurels, and he thought deservedly so. It was known, however, that quite large gall-stones ulcerated through into the intestine and the opening afterward closed, as shown post mortem, and it might be that the opening made by the button would also close ; but unless it should become completely occluded it would permit the passage of the bile. When gall stone was the cause of the obstruction it should, if possible, be removed from the duct. The cases especially adapted to the use of the button were those of malignant obstruction of the duct, since the disease would probably run its course before there was time for cicatricial occlusion. He attributed the improved statistics of to-day to the surgeon's ability to do clean peritoneal work. Dr. B. F. Curtis thought that all must admire the in- genuity of the Murphy button, but, as it had already been stated, there were objections to it. There was hope that in the future the ingenious contrivance would triumph over the danger of stenosis and intestinal obstruction. The principal argument which had been advanced in favor of mechanical aids was a saving of time. There was no doubt that the length of the operation in certain cases had a very important influence on the result. Operations were for two classes of cases, namely, the chronic, where the question of time was of little impor- tance, and the acute, where the question of time was of

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