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Offers the Young Graduate for Medical Training. By Henry A. Christian. 3. The Medical and Surgical Aspects of Perforating Ty- phoid Ulcers. By Richard H. Harte. 4. Perforating Typhoid Ulcers, By Frederick C. Shattuck. 5. Mistaken Diagnosis in Cases of Typhoid Perforation. By C. L. SCUDDER. 6. Perforating Typhoid Ulcers, By Farrar Cobb. 7. The So Called " Ochsner Muscle " of the Duodenum, By Walter M. Boothby. 3, 4. The Medical Aspects of Perforating Typhoid Ulcers. — Harte remarks that perforation Purchase Cefaclor Online of the bowel in typhoid fever is a much more common condition than is generally supposed, being responsible for about one death in everv three cases. The most common time of perforation is between the fourteenth and twenty- first days of the disease and occurs in all grades of se- verity, Cefaclor Cd from the ambulatory to the hremmorrhagic type, and does not seem to be any more common in the haem- orrhagic than in Purchase Cefaclor the milder types of the disease. The ileum is the most frequent site of perforation, in the majority of instances the perforation occurring within twelve to eighteen inches of the ileocoecal valve. The ne.xt most frequent sites of perforation are the appen- dix and the cjecum. Pain of some kind is Cefaclor Antibiotic present in 75 per cent, of all cases. In 50 per cent, of the cases the onset is sudden and severe Cefaclor Antibiotics and of increasing intensity, localizing itself to a special zone. In 20 per cent, of the cases the pain is of slow onset, not localized, with general distribution. In some cases no pain is Cefaclor Price com- plained of and the usual symptoms of perforation are absent. Tenderness and rigidity are present to a cer- tain extent in all cases. When perforation is suspected the temperature should be taken every hour, as it is ■only in this way that definite conclusions Cefaclor Cost can be drawn with regard to any marked variation in this symptom. Distention is a late symptom of perforation, usually not making its appearance until some hours after the per- foration has occurred. The obliteration of the liver dullness is not regarded as a reliable Cefaclor 500mg sign of perfora- tion. The Order Cefaclor Online study of the leucocytes is of little aid, al- though occasionally their increase may make us Order Cefaclor more positive of the diagnosis. The differential count is of no practical value. Nature may occasionally close one or more perforations, but the only rational procedure where perforation occurs is surgical intervention. No case is too desperate for an attempt, as it has not in- frequently been noted that the mild cases succumb and tile more desperate ones recover. — Professor Shattuck states that perforation is the gravest complication of typhoid fever. Fortunately it is rare. Of 2,047 cases of typhoid treated in the Massachusetts General Hos- pital in the past ten years, it has been known to have occurred in 30, or in 1,4 per cent, of the cases. It is most liable Cefaclor Tablets lo occur in the third week, but may occur at any time after the middle of the second. It may occur in the first or second relapse, the primary attack or attacks having run a favorable course. There is Cefaclor Ceclor no relation between the severity of the case and the liabil- ity to perforation. The duties of the physician with regard to perforation in typhoid arc four- fold: (i) He must know the symptoms suggestive of its occurrence; (2) he nnist be on the watch for them; (3) he must sec that the nurse or altend.inl knows and is alive to Buy Cefaclor Online are symptoms not to be lightly regarded. Vomiting may or may Cefaclor Monohydrate not occur. Rapidly Cefaclor 250mg increasing leucocytosis is highly con- firmatory, but we must remember that operation has proved the existence of perforation and peritonitis with- out increase in the white count. Here, as in other diag- nostic problems, it is the association of symptoms and signs — the whole picture — which counts rather than any one symptom or sign. Cefaclor Generic Rapidly increasing disten- tion in connection with the above indications suggests that peritonitis is general. 7. The So-called ' ' Ochsner Muscle ' ' of the Duode- num, — Boothby has examined twentv-five intestines. In none could he demonstrate macroscopically the ex- istence of any sphincter muscle, by palpation thicken- ings of the wall could be demonstrated, but in every instance this thickening could be accounted for by ir- regularities of the mucous membrane. He therefore concludes that the musculature of the duodenum (es- pecially the circular layer) presents certain irregulari- ties in its thickness ; these irregularities are slight as compared with the average thickness of the muscle, and, compared to a true sphincter, the pylorus, are Cefaclor Generation in- significant. In short, he found no grouping of circular fibres in the duodenum which could be considered an anatomical sphincter muscle, though Buy Cheap Cefaclor undoubtedly there

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