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len, the pain is constant and severe, and is local- ized about the affected region. The superven- tion of gangrene in the obstructed bowel is marked by diminution in the pain, provided peri- tonitis has not already arisen. Obstruction in the large bowel excites but slight pain, due to the fact that peristalsis in the large intestine is nor- mally much less active than in the small. Constipation becomes more and more complete as the case progresses. Enemata at first may cause the escape per rectum of the gas and the fasces which are in the intestines below the point of constriction, which fact may mislead, and cause precious time to be lost in vain attempts to open the bowel. Cathartics likewise tend greatly to exhaust the patient because of the increased violence of peristalsis caused thereby, with its consequent greater pain and expenditure of nerv- ous energy. Distention gradually increases in the intes- tines above the occluded point. In intestinal ob- struction resulting from appendicitis, the site of obstruction is always in the small intestine, and most frequently Order Oxybutynin Online in its lower region. Meteorism is most prominent in the mid part of the abdomen, and, in the acute cases, not usually so sufficiently localized as to be perceptible by palpation, or in- spection, as confined to a definite loop. Disten- tion in this variety of obstruction is rarely con- Generic Ditropan spicuous until peritonitis supervenes, because the Purchase Oxybutynin constant vomiting and eructations of gas serve to relieve the accumulation. Ditropan Online Later on, distention, due to the peritonitis with its consequent paraly- sis of the intestines, even without perforation, may become very diffuse and general, and embarrass the heart and lungs by pressure. Perforation may occur, and give the signs of free air and fluid in the peritoneal cavity. The higher up the ob- struction is situated, the less is the distention. Abdominal rigidity and tenderness at first are Order Ditropan Online very slight, and limited to the portion of the abdomen in front of the constricting point. There ma}' be some general cutaneous hyperassthesia. Later on, as the peritonaeum Purchase Ditropan becomes Buy Ditropan Online involved, the rigidity and tenderness both are marked, at first localized, then becoming more and more gen- eral as the peritonitis spreads. The intestine at the constricted point may become so distended with fluid as to give rise to a localized area of dul- ness. A mass is usually not palpable in the case of an obstruction by a simple band. A volvulus or hernia may give the Oxybutynin Online sensation of an indefinite mass, but this is the exception. The pulse at the outset may be rapid and feeble, from, sudden shock to the abdominal sym- pathetic. In this it differs from simple intestinal colic, in which the pulse remains full and not rapid. As the shock Purchase Ditropan Online is recovered from, the pulse approaches somewhat the normal, Buy Oxybutynin or may be even slower than normal. Later it becomes rapid and feeble as the peritonitis spreads, or the poisonous intestinal contents are absorbed. The leucocyte count is usually of little help. In the first case to be reported, with 23 inches of gangrenous gut, it was a trifle above the normal. Harvey Cushing, Buy Cheap Ditropan in 1898, concluded that a leu- cocytosis of 18,000 to 20,000, in patients present- ing symptoms of obstruction, was pathognomic, and sufficient to form a rational basis for oper- ative interference. Bloodgood has recently Buy Oxybutynin Online ex- pressed very similar conclusions, and affirms " that in the majority of instances the leucocyte count is from 15,000 to 20,000: higher counts, 25,000 to 35,000, are usually associated with gan- grene or peritonitis." This question of the value of the leucocyte count in abdominal diseases is a much vexed one at the present time, and a satis- factory interpretation of the varying counts has not yet been arrived at. The earlier promises that this examination held out have not as yet been fulfilled, for many of us have learned by sad experience not to place Buy Cheap Oxybutynin a great deal of de- Buy Ditropan pendence upon it. It is Order Ditropan only of value when con- sidered in conjunction with all the other signs. A low count, with the other cardinal symptoms well developed, should be left out of consid- eration Order Oxybutynin when debating the Purchase Oxybutynin Online pros and cons of an operative procedure, since we have often found that there may be a normal leucocyte count with the abdomen full of pus. This low count sim- ply means that the system is too overwhelmed and depressed to manufacture sufficient leucocy- tes to combat the sepsis. A high count would mean that some grave condition was present, such as gangrene or perforation, and it would simply strengthen our view that some operative interference was urgently required. It is also Cheap Ditropan of interest to note that as soon as symptoms of gen- eral septiciemia are present, Generic Oxybutynin bacilli coli com- munes may be found both in the urine and blood (Gallazzi).

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