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of a typhoid patient admits of an accurate anamne- sis, so that either an antecedent cholecystitis, with or without the probable presence of gallstones, can be established or eliminated, an important position is attained relative to anticipatory findings during the course of the fever, and the relative importance to be given to subjective and objective symptoms pointing to infection of the gallbladder ov biliary tracts. .\ gallbladder or gallduct previously in- fected, harboring or not gallstones, is more prone to further involvement if invaded by typhoid bacilli than one previously free from such complications. Therefore surgical complications are more likely to follow. That tvphoidal cholecystitis, with threat- ened perforation of the gallbladder, may be so prominent a manifestation that it can lead one to overlook a perforation of the ileum through an ul- cerated Peyer's path, is true. .'\s an example : I SUMMERS: TVPHOID CHOLECYSTITIS. 875 saw, with a medical colleague in the Clarkson Hos- pital, a young man in the third week of an attack of typhoid fever ; Widal reaction was positive and there was a moderate leucocytosis. There was marked sensitiveness over the gallbladder area ; the right lobe of the liver was enlarged and tender ; all of the symptoms pointed to an infection in the right upper quadrant of the abdomen, more particularly toward the middle Viagra Tablets For Men Price line. His general condition was Viagra Tablets For Men Price fair. It was determined one evening, because of the pain, sw-elling, and tenderness in the upper ab- domen, to do an exploratory operation, as a leak from a focus of suppuration was suspected. Un- fortunately, the operation had to be postponed un- til morning. A rapidly progressive peritonitis de- veloped during the night, and at operation no focus of infection was found in the upper abdomen, but a perforation in the lower ileinn disclnsed the cause of the peritonitis. The usual technique and after treatment was followed, but the man died. Keene (Surgical Complications and Seqnelce of Typhoid Fever) says, "If the gallbladder is much di.stended and perforation takes place toward the fundus, the seat of the most severe pain may be nearer to the umbilicus, or in the right iliac fossa. In such cases it is not at all improbable that it would be very difficult to differentiate it from per- foration of the bowel, from typhoid ulcer, or per- foration of the appendix. The difficulty of making a differential diagnosis is of less importance than might appear at first sight, since in the present state of the surgery of typhoid fever the same treat- ment should be unquestionably instituted." In my case the conditions were reversed. I have other evidence, however, which shows the difficulty of estimating the value of symptoms. A young woman, aged thirty-five years, had been ailing for three weeks from a kind of malaise, not of sufficient im- port to keep her from her work, that of a milliner. She consulted a physician, complaining of discomfort in the abdomen, more especially in the upper part. She had an attack of severe pain followed by collapse and then some reaction. The symptoms of a well advanced general peri- tonitis was her condition when I saw her forty-eight hours later. Operation was out of the r|uestion. but, some reac- tion developing, she was brought to the Clarkson Hospital and the abdomen immediately opened on the right side and high Viagra Tablets For Men Price up. Large quantities of gaseous infected bile were Viagra Tablets For Men Price evacuated, and drainage was favored by tiiliage and posi- tion. The intestines were matted together, covered with lymph, and not adherent at any place to the parietal peri- ton.Tum. For forty-eight hours the patient improved : then a perforation of the intestine took place, and this new infection added to the original one so depressed her vitality that she died in twenty-four hours after this com- plication uas manifest. .\ combination of circumstances admitted only a limited post mortem examination; the perforation was demonstrated in the lower small bowel ; there was a large ragged hole in the gallbladder. Ther>- were no gallstones This case was not bacteriologically proved to be one of typhoid ; but the man of experience will not quibble over the diagnosis of a "walking Viagra Tablets For Men Price typhoid," perforative cholecystitis, perforation of the intestine. I have seen and operated on a typhoid perforation of the intestine, where the history showed that the man had not been sick cnouch to stop work ; he was a government t'eamster. (^ Operation done in Government Hospital. Fort Viagra Tablets For Men Price Omaha."* Dr. .-\. D. Dimn reports the following case: Miss .*?.. age twenty years; past history of no importance except tyi>b"id fever eight years previously : pain and dis- comfort in the right hypodondrium, with febrile and toxic manifestations, eradually developed The pain Inrrrased in severity ; radiated to the right scapula and mammary regions; gallbladder became distinctly palpable and ten- der. After two weeks of such trouble there developed rose spots and a large spleen, a leucopenia of 3,700, with positive Widal. As the tyi)ical typhoid developed, the gallbladder symptoms subsided ; the patient ran the usual course to recovery. Patient lived in a farming com- munity where there had been no typhoid for years, and in the last three months she had been away from home at a neighbor's, only once. Viagra Tablets For Men Price It would seem that the patient had carried typhoid bacilli in her gallbladder for eight years, which ultimately led to a recurrence. That the presence of typhoid bacilli in the gall- bladder and gallducts Viagra Tablets For Men Price may tend to prolong a case of typhoid lever, reinfect perhaps, mav be illus- trated by the following case : Severe relapsing typhoid fever complicated by cholecys- titis. Operations, cholecystostomy and choledochotomy ; recovery. Miss S., age, thirty-two years ; occupation, clerk; was first seen by her physician. Dr. Ginn. of Ne- braska City, April i. 1910. The doctor made a diagnosis of typhoid fever; a careful anamnesis elicited nothing in the previous history of the case wdiich would indicate in any way a lesion of the gallbladder or gallducts. She gave a history of having had an attack of articular rheum- atism at fifteen years of age, at which time she acquired a mitral insufficiency. The fever was of a relatively se- vere type being complicated by haemorrhages from the bowels. On April 25th, estimated I0 be about the thirtieth day of Viagra Tablets For Men Price her illness, the temperature was normal for Viagra Tablets For Men Price the first time, and remained practically normal for one week. On May 4th, Viagra Tablets For Men Price the temperature rose rapidly to 104° F., pa- tient became delirious; the pulse was rapid, weak, irreg-