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mental condition normal. There was pain the throat when the tongue was extended, and speech and deglutition were accompanied by pain. Tile Online Cialis Review jaw muscles w-ere contracted. The left arm and fore- arm were more involved than the right, the grip of the left hand being Online Cialis Review practically powerless, while that of the right was below Online Cialis Review normal. She complained of pain under both knees when the legs were extended. After considerable mental concentration, movements of the legs were executed with an abnormal degree of effort. Case V. — I., age Online Cialis Review ten years. Temperature 105° F., pulse 102, respiration 24. There was pallor of the skin; the cheeks were flushed ; the eyelids were edematous, and slightly ecchymotic ; Online Cialis Review sordes moderate, and severe epitaxis. The patient had delirium during the night, due doubtless to the high temperature. She had been sick for from ten to twelve days, and the muscles were as yet but slightly involved. The biceps were moderately contracted, and a gripping by the hand or drawing out of the arm produced some Online Cialis Review pain. The legs were somewhat more involved than the arms, being drawn up with the musculature moderately firm and painful on pre^sure. In the remaining six children the severity of the symptoms lessened with the successive decreases in their respective a.ges. In the younger two there were mild fever, irritability, increased eosinophilia. and no demonstrable muscle pain. The mild symp- toms ni the younger children may be explained on the basis of the smaller amounts of sausage eaten, the degree of infection depending directly upon this factor. The iUness in the case of Mr. A. was a moderate infection of about the same degree as that oi Mrs. A. It is interesting to note that eosinophilia was most marked, forty-two per cent., in the patients who wore in the early stages of muscl'- involvement : while only twelve per cent. CUM MING: TRICHINOSIS. 443 was foiiiKi in the patient with the most extensive muscle invasion. In those with the muscle rigidity of a week or more the percentage ranged from twelve to twenty-four per cent. The average white cell blood count, taken about the twelfth day of illness, for the twelve patients is as follows Online Cialis Review : large mononuclear, 5 ; small mononuclear, 1 1 ; neutro- philes, 41 ; eosinophiles, 26: basophiles, o.i. Online Cialis Review Differential diagnosis. — The extent of the in- vasion of the muscle groups was indicated by the degree of rigidity, the flexion, and the pain on pressure. The contractions were wholly involun- tary and tonic in nature and were apparently due to a tetanuslike toxin. The reflexes, which were elicited after repeated attempts, were exaggerated. The Online Cialis Review various limb muscle groups were apparently quue uniformly involved. Even though the legs could be flexed on the thigh this did not mean that the flexor groups were more involved, for the greater involvement of the flexors would seem to be only apparent and not real. The combined re- flex muscle contractions of the larger groups, the flexors, overpower the contractions of the smaller groups, the extensors. It was noted in these pa- tients that after they had been standing for some time the reflex tonic contractions of the leg flexors and the foot extensors were finally broken, so that the legs became straight and the body rested on the heels. The dili'erential diagnosis between trichinosis and tetanus is not difticult, as in the latter disease the early involvement is unilateral, aft'ecting first the muscle groups in the immediate vicinity of the focus infection, then the jaw muscles; only later is there a generalized tetany. On the other hand, it IS to be noted that the muscle involvement in trichinosis appears first, ten days to two weeks after the onset Online Cialis Review of symptoms, in the legs, then in the arms, and finally, in severe Online Cialis Review cases, in the tongue and jaw muscles. This involvement is bilateral, though there may be a slight difiference in degree. The reflexes in tetanus are easily elicited, whereas in trichinosis they are difficult to elicit, but when there is response it is, as in tetanus, exaggerated. The prodromal symptoms, the edema of the eyelids and face, Online Cialis Review the eosinophilia and the high temperature of trichinosis are absent in tetanus. The differential diagnosis from typhoid is to be made by the early edema of the eyelids, conjunc- tiva;, and face, appearing later in the lower limbs, the clean red tongue ; eosinophilia ; the finding of trichinae in the muscles, bloodstream, or stools ; the dyspnea ; the involuntary contractions ; and an Online Cialis Review ab- sence of a positive Widal test. Ihe early differential diagnosis of trichinosis de- pends chiefly on the edema of the eyelids, Online Cialis Review the eosinophilia, and a history of undercooked pork having been eaten. Many mild cases undoubtedly go unrecognized and the symptoms, edema and eosinophilia, recognized as pathognomonic, must be kept in mind Online Cialis Review for the diagnosis of isolated cases of trichinosis. In the group of cases here reported, sausage from one hog formed one of the chief articles of diet for a week or more ; consequently the ingestion of repeated large doses, especially by the older members of Online Cialis Review the family, resulted in severe infections and well defined symptoms. A single dose of the same sausage, or of any measly pork, infective to the same degree, might produce symp- toms so indefinite as to pass unrecognized. Treatment. — The treatment consisted in mild pur- gation over a period of a couple of days, after which time a liberal dose of thymol was given fol- lowed by Epsom salts. As accurately as could be determined the thymol treatment was given about the twelfth day of illness. Inasmuch as the in- gested trichina may survive in the intestine for as long as twenty-five days, their destruction and elimination should be accomplished as soon as a diagnosis is made. Following the thymol treatment there occurred in all Online Cialis Review cases a drop in the temperature curves almost to normal without a subsequent rise. Whether or not this was due to a destruction and expulsion of the worms by the thymol cannot be definitely stated. It would appear, however, from