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over ioo°, and would always subside on her going to bed ; no exudate ; everything clear. On opening the abdomen, the colon looked normal. I found the head of the colon easily ; there were no adhesions, but there was no appendix. There was a scar at the union of the lateral striae, but there was no appen- dix. I continued my search for a probable cause of the trouble, and found a small ovarian cyst on the right side. This was removed and the patient was ilischarged in two weeks. There has been no trou- ble since. It is my belief that during her attack of appendicitis there must have been an abscess which discharged through the gut and Nizagara Online so led to a spon- taneous cure. Two summers Buy Nizagara Online ago I met a gentleman whose wife was formerly a patient of mine. I inquired about his family and learned that he and his family were living at the seashore permanently for the good of the children. They were all well, he said, except his wife, who had a chronic catarrhal appendicitis, but refused to be operated upon. She was afraid of the operation, and when the pain was very se- vere she would go to bed for a few days and get over it. This occurred every month or two. I heard nothing more until last December, when the husband telephoned to have me come to his home jirepared to operate on his wife for appendicitis, statjing tliat she had gradually lost in health, was practically an invalid, and had at last made up her mind to have her appendix removed, adding that I had better make haste, for she was subject to pass- ing fancies and might change her mind. I could not arrange to see her, however, at that time, and a week passed before I had a chance to examine her. Four years ago she was the picture of health ; two years ago sh(; began having pain in her right side, which was repeatedly diagnosticated as ap- ])endicitis. The trouble continued for two years, and at the time of her examination she looked the shadow of her former self. I examined her, and she had a floating kidney on the right side, easily recognizable. Last April I saw a young woman who was suffer- ing with excruciating pain in the epigastric region. The onset was abrupt and required opiates ; the bowels were constipated ; there were persistent but ineffectual attempts at vomiting; the pulse was small but very rapid ; the tem])erature normal ; the woman was very obese ; there was localized tenderness over the epigastric region and nowhere else. I thought of biliary calculus, but finally excluded this, for her stools were normal in color ; there was no icterus ; the ]win was directly in the centre of the epigastric region. The only thing in favor of biliary trouble was her inability to digest fats. Milk acted like an irritant poison even when peptonized ; so did starches in the way of toast ; nothing but beef broth in small doses would do. It was at this time that I read Dr. Otto H. Schultze"s article on pancreatic fat necrosis, which came out in April, 1901. The case answered precisely the requirements. There were slight elevation of temperature, rapid pulse, and persistent tachycardia ; the patient was very obese, and the pain was of an excruciating character in the epigastric region ; and so by exclusion I strongly favored the diagnosis of pancreatitis with probable fat necrosis. After some little experiment- ing in the selection of a proper diet, it was estab- lished that beef broth was the only thing that she could take and be cotuparatively free from pain. when supplemented with pepsin and hydrochloric acid ; milk, starches, meat, and alkalies acted as ir- ritants. This diet of beef broth was kept up for weeks at a time, practically from April to January of the next year, and if deviated from even to a slight degree w-ould be immediately followed by se- vere pain and prostration. She naturally lost a great deal of weight. It was during one of these digressions during December, when a little toast and steak had been taken, that she complained for the first time of tenderness in her right side, together with pain in the epigastric region. This was the first symptom that suggested appendicular trouble. In two days there >vas a slight exudate, which dis- appeared in a week's time, due to rest in bed and ice applications. The temperature did not rise over 100°, although the pulse remained high, varying be- tween 100 and Nizagara Tablets 120. After the exudate and tender- ness had disappeared entirely, she was operated upon for appendicitis and a diseased appendix was removed. She returned home in three weeks and has had no trouble since ; she eats and drinks what- ever she chooses. A woman, aged about forty-two, while traveling abroad three years ago, was taken sick with what was diagnosticated as appendicitis, at Zurich. Order Nizagara An operation was proposed, but she refused, and recov- ered perfectly, so that she continued her journey. On reaching Berlin, several months later, she was taken sick again with what was diagnosticated as hypertrophic cirrhosis of the liver, and the attend- ing surgeon emphatically denied the likelihood of her having had appendicitis when sick at Zurich, and ordered her to go to Carlsbad to take a course of treatment there. She recovered and returned to this country. In February, 1901, she was taken sick with appendicitis. This was a typical case. It was mild in its course: she recovered in throe weeks, and during her illness promised to have her appendix removed as soon as she had fully recovered from that attack. On recovering, however, she regretted her promise and refused an operation. She re- mained well until May, 1901, when she was sud- denly taken severely sick with most excruciating pain in the epigastric region, radiating to the right over the Buy Nizagara liver region. Tlie pain was so severe that she fainted ; it \vas colicky in nature and accom- panied by a marked prostration. Morphine was ad- ministered and the attack was regarded as biliary colic. After the clYect of her, r.iorphine had worn off, the pain in the epigastric region returned, was constant in character, and was associated with September 6, 1902.] STAEHLIN: DIFFERENTIAL DIAGNOSIS OF APPENDICITIS. marked dj'spnoea, a regular gasping for breath. She

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