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if any nourishment was taken, faecal vomiting ensued. The pulse was 100 beats to the minute. Laparotomy was immediately per- formed at the home of the patient. An incision, seven inches long, reaching about three inches above the navel, was at once crowded full of much-distended, purple, deeply congested intes- Order Trileptal Online tines, which were received in hot towels. The gut was filled with fluid masses principally. In Order Trileptal passing my hand into the ab- domen and moving it about among the coils of gut in various directions, it Cheap Trileptal was finally arrested by a tightly conglomerated, immovable, Buy Cheap Trileptal and intensely distended Purchase Trileptal Online portion of the ileum, which was found to be immovably fixed near the margin of the smaller pelvis in the right iliac fossa. Being exposed, this immovable convolution was found Trileptal 150 Mg to consist of a large loop of gut that had slipped through, and was strangulated in an aperture formed by a short, solid band of connective tissue extending from the brim of the pelvis to the mesentery of the ilium. The band being severed, the contents of the distended intestine were at once seen to pass into Trileptal 150 the empty distal segment. Owing to the col- lapsed condition of tiie patient, the anaesthesia was very difiicult and much interrupted. Whenever insensibility was produced, deep cyanosis and stoppage of Cost Of Trileptal the pulse warned me from con- tinuing the use of ether. The next moment, however, violent contractions of Buy Trileptal Online the abdominal muscles hindered the progress of the operation in a very disagreeable manner. A carefQl revision of the entire intestine was not deemed advisable under these cir- cumstances, and closure of the abdominal cavity was Trileptal 450 Mg proceeded with in the hope that the strangulation which had been relieved by cutting the band above mentioned would be the only trouble present. It was very noticeable how much the distension of the small gut was diminished by the passage of a large part of its contents into the distal part of the intestinal canal. Never- theless, replacement of the abdominal contents and closure of the wound was by no Trileptal Vs Tegretol means easy. Kuemmel's proposal of tucking the edges of a disinfected towel under the abdominal parietes, using this artificial diaphragm for the retention of the intestines while the stitches were passed and closed, was found of great utility, and materially helped a rapid closure of the wound. Under vigorous stimulation the patient rallied unex- pectedly well from the shock. Her temperature, however, did not fall Trileptal Acne as was hoped, but after a short pause rose to 103° F. with all the usual symptoms of intense general peritonitis. Food was vomited, the distension of the abdomen became more marked, interfering with respiration, and therefore it was deemed advisable to commence with the administration of a saline cathartic, of which two half-ounce doses were taken, but almost immediately rejected. On June 16th, about twenty hours after the operation, the patient suddenly collapsed during- a spell of vomiting, her Trileptal Tablets last exclamation being a wail of com- plaint about a sharp pain in the belly. As no post-mortem examination was permitted, it could not be ascertained whether death was due simply to general peritonitis, the beginnings of which were already found at the time of the operation ; or whether a second band was overlooked and the strangulation thereby produced left un- relieved ; or, finally, whether perforation of a diseased part of the intestine was caused by the use of the laxative. The principal corollary and lesson of the case, however, is the fact, which I do not hesitate to express with some emphasis, that procrastination robbed the patient of other- wise good chances of recovery. Had laparotomy been per- formed two or three days before the advent of peritonitis, a leisurely and methodical examination of the entire in- testine would have been Trileptal Generic Name possible, both on account of the 178 GERHTBR: ABDOMINAL SECTION FOR INTESTINAL OBSTRUCTION. [N. Y. Mbd. Jour., ^ood ooiitlition of tliu ptitioiit and inaiitly bocaiine oxtronic tviiipHiiitOH \va.s absfiit nt tliat tiiiiu. C\sK U.-Siimiiol (iros^, a llohrtnv tailor, Trileptal 60 Mg lliirly-tliroo ycMirs »)l(l, luitl ill till' iiiorniii^; of .lannnry 21, 18Hi), Tegretol Vs Trileptal niady a lioarty inoal of lioiT Trileptal Coupon ami clioose. Alttmt noon of tlio sanio day sliiir|) rolio I'oniiH'iioil liiiii to abandon liis work. Tlio samo ovoninff liis sullViinjis vvoro aii^'inontcd l)y votnitin;;, wliicli iv^jnlarly foUowod whonovor tlio pationt (luourliod his burniii)^ tiiirst by drinking. Tlie case bore tlie a.spoet of an IndigeHtion, and waw troatod aooordiiifjly, tlio family physician administering ono stroller catliartio after tlio other. Only after the cathartics wore all rojoctod, iind fjroat tvnipanitos witli fevor had set in, were eno- iiiata tried, but to no purpose. On .January 2.'5d fa>cal vomitinfr appeared, and on January 27th I found the patient sutToring from rvanosia, owinj; to the enormous distension of the belly, which was Trileptal 135 Mg very painful on touch everywhere. In the right iliac fossa nn increased resistance could be made out distinctly, but the percussion sound there was clearly tympanitic. The tempera- ture was lOi'C)"" F., pulse 112 a minute, respiration hurried, and a clammy perspiration covered the patient's skin. In sj)ite of his jioor condition, lai)arotomy was Trileptal Cost suggested as the only luoans of relief, and the man was accordingly transferred to Mount Sinai Hospital, where chloroform was administered. Dark, brownish-])urplo, much-distended gut escaped through the rather extensive abdominal incision, and was cared for in the usual manner b}' being wrapped up in hot towels. Most of the small intestine had to be thus withdrawn from the abdominal cavity before a recognition of the existing conditions was ren- dered possible. In the right iliac fossa a convolution of in- testine was found to be firmly fixed, and, being well exposed, it became evident that the apex of the vermiform appendix was attached to the transverse mesocolon on its lower aspect, where the place of attachment was marked by intense reddening of the peritonaeum, back of which a rather massive swelling of

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