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February 25, 1905.] buy hydrochlorothiazide online TAYLOR: PERFORATION LV TYPHOID. 381 will be blurred beyond recognition. If, when called to a case, we are told that it has run an un- eventful course, that there have been no pro- nounced hydrochlorothiazide price abdominal symptoms, no mental confu- sion, or delirium, to mask an expression of symp- buy hydrochlorothiazide toms, that the patient was, up to a given time, comfortable, and, while having an action of the bowels, was taken with sharp continued pain, ten- derness, and muscular rigidity; perhaps with chill, reduced temperature, increased pulse rate, and vomiting, symptoms of shock ; we have a chain of evidence hydrochlorothiazide online pointing to perforation, as closely linked as that upon which we commonl)' have to rely in most acute peritoneal infections. A large major- ity of the cases I have seen have presented a clin- ical histor}' as clear as that indicated by the above described group of symptoms. On the other hand, it is easy to see how such symptoms may be masked if the patient is de- lirious, if there is abdominal distention and gas- troenteric disorder, and if there have been daily marked variations in pulse and temperature. For- tunately, in my experience, a large number of ty- phoid cases are atypical in type and the gross symptoms which would mask the symptoms of perforation are probably in the minority. It should be borne in mind that other conditions than perforation may, during the existence of typhoid fever, give rise to symptoms of local and general peritonitis. Incomplete perforation may, and I think often does, give rise to cheap hydrochlorothiazide local perito- nitis and adhesions. In one of my cases, a pre- perforative abscess formed with later rupture and flooded the peritoneal cavity with pus and intes- tinal debris. The lower portion of the ileum en- tered into the formation of the abscess wall, and in hydrochlorothiazide cost this portion of the ileum was a large perfora- tion. I do not believe that adhesions occur after perforation of the small generic hydrochlorothiazide bowel, but I do think that it is not infrequent in the preperforative stage, and that it possibly saves many lives. It is also essential to take into consideration the occurrence of acute cholecystitis, appendicitis, and the infec- buy esidrix tion, suppuration, order hydrochlorothiazide online and discharge of the mesen- teric and other intraperitoneal glands, and also the possible thrombosis of intraperitoneal blood esidrix 25 mg vessels. buy cheap hydrochlorothiazide While these are possibilities relatively infrequent, perforative purchase hydrochlorothiazide online cholecystitis and throm- bosed mesenteric vessels may give rise to acute symptoms of local and general peritonitis. I have seen a number of cases of acute chole- cystitis occurring during the course of typhoid fever. In several instances, I have mistaken ty- phoid fever in its incipiency purchase hydrochlorothiazide for appendicitis, and I have also seen the two conditions coexist. I have not, however, seen perforative peritonitis during typhoid fever due to esidrix or zaroxolyn any cause, except ty- phoid perforation. Usually the differentiation has to be made only between typhoid fever and the conditions mentioned. In exceptional in- stances, an unrecognized, ambulatory case of ty- phoid fever may have perforation, and the only symptoms presented will be those of perforative peritonitis. The symptoms of intestinal haemorrhage may at first simulate those of perforation, and this order hydrochlorothiazide is notabl}' so when the conditions coexist. A case recently seen with Dr. E. J. Moseley, Jr., and Dr. William S. Gordon, presented slight symptoms of abdominal pain, profound collapse, reduced tem- perature, increased pulse, anxious expression, and pinched features, and this was followed in six or eight hours by reaction. I was at first misled, but there was in this case an absence of the acute, lasting pain, tenderness, and muscular rigidity. Later on, progressive improvement and large bloody stools cleared the obscurity in the diag- nosis. No feature in the diagnosis is more important than the sudden transition from the quiescent con- dition to one evincing acute intraperitoneal inva- sion, and no symptoms of the last condition are more uniform than acute, lasting pain, and ten- derness with muscular rigidity. With these, we may or hydrochlorothiazide mg may not have the usual symptoms of shock. The limits of this paper hydrochlorothiazide tablets will not permit me to analyze in detail the relative value of pain, tenderness, rigidity, vomiting, hiccough, reduced temperature, increased pulse rate, distention, liver and flank resonance, inhibited peristalsis, the value of blood count, blood pressure, the injec-

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