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routine practice in every questionable case of gas- trointestinal trouble of making functional tests, palpating the stomach, and investigating with the endoscope and the x rays. Beginning with the esophagus, this should be examined for stricture in every case of persistent vomiting or regurgitation soon after meals which is not readily explained by the presence of some known condition. He intro- duces first a stiff catheter, and if this meets with an obstruction, withdraw^s it and introduces a soft catheter, as he thinks more can be learned from the two than from either one Order Salmeterol alone. The x ray will clear Buy Cheap Salmeterol up the diagnosis between an hourglass stomach and one that has been contracted by Order Salmeterol Online a cancer. Palpation is not always reliable, for this requires skill, and under certain circumstances the tumor cannot be Generic Serevent felt, but nevertheless should al- ways be practised. The first postulate for the re- cognition of pathological conditions in this manner is a knowledge of how the normal conditions feel, yet he has known experienced specialists to mistake a contracted loop of intestine, or the tense belly of the rectus abdominis for a neoplasm. When a tumor has been made out in the stomach the diag- nosis of carcinoma is not positive, though such is its nature in the majority of cases. When the tumor is at the pylorus its presence can be Order Serevent recog- nized from the symptoms of stenosis more quickly than when it is elsewhere in the wall of that organ, because in the latter place it is apt to give no marked local trouble, and the accompanying gen- eral symptoms may be the first to attract attention. To differentiate between cancer and ulcer of the stomach the examination of the contents is of very great importance. Ulcer is accompanied as a rule by superacidity. sometimes w^ith normal acidity and supersecretion, only exceptionally Buy Salmeterol Online by sub- acidity, \yhile in carcinoma free hydrochloric acid is almost regularly absent, subacidity is rare, and lactic acid is often present. He has never found lactic acid in a well marked case of ulcer, but he has repeatedly seen cases in which the history and course seemed to indicate Order Serevent Online ulcer with an absence of acidity or with subacidity and lactic acid, which proved on histological examination to be carcinoma. Inversely he has seen large tumors with super- acidity which i)ri)ved histologically to be ulcers. Hence he believes that the diagn(jsis of carcinoma should be made in every case of pyloric stenosis, whether a tumor can be felt (jr not, when free hy- drochloric acid is absent, or lactic acid is present. I le found achylia in scarcely three per cent, of S.^o noncarcinomatous cases, a lack of hydrochloric acid in only seven i)er cent, of nearly 1,000 cases of noncarcinomatous diseases of the stomach, while hydrochloric acid was wanting in over seven- ty per cent, of 150 cases in which carcinoma was l)resent. The diagnosis of cancer of the intestines is possible only through symptoms of stenosis, or the demonstration of a tumor, and, even then, the diagnosis is only probable. He sug.gests giving the ])atient a dose of a purgative mineral water, and ])alpating the intestines a few hours later. An ac- cumulation of fluid may be found above the con- stricted portion. Symptoms of disease of the lower portion of the intestines, such as hemorrhage, Buy Serevent Online mucus, or tenesmus, should lead the jihysician to make a rectal examination, although he thinks that this is not done in a great many cases, so that the disease is not recognized until late in its course. He sees many patients yearly who have been treated for chronic intestinal catarrh, at Carlsbad and else- where, without endoscopic examination, or even digital exploration. Such examinations are neces- sary in order to make an early diagnosis. Gangrene of the Extremities and Its Treat- ment. — Hans Ehrlich and Marian Maresch report eighty-one cases Buy Cheap Serevent of gangrene met with in von Eiselsberg's clinic between April, 1901, and the end of March, 1913. The gangrene was due to elec- tricity in one case, to embolism in two. to freezin.g in two, to ligation of the popliteal artery in three, to arteriosclerosis in forty-four, to diabetes in twenty-nine. In Purchase Salmeterol the case caused by electricity a boy laid his hand on a live wire ; amputation of the arm was necessary. The cases of embolism were due to puerperal sepsis. The popliteal artery was ligated in one case because of a wound, in two be- cau.se of aneurysm. The cases of arteriosclerosis are of more interest. The patients had usually suffered for years from paresthesias, chilliness of the limb, rheumatic pains, or intermittent limping. The lower limbs were the ones almost always af- fected, the process usually beginning in the toes, more rarely in the skin of the back, or the sole of the foot, or of the leg. The anemia or cyanosis of the skin may last a long time, with considerable pain, before the patients die. P'requently the pro- cess has from the start an inflammatory character, Purchase Serevent beginning as Buy Serevent a paronychia, or an ulcer of the ball of the great toe, Generic Salmeterol and then suddenly the true state is Buy Salmeterol revealed by an intense lymphangitis and a dis- turbance of Purchase Salmeterol Online the circulation with edema and cyanosis of the leg. In many caes the gangrene starts from a slight local trauma, such as the pressure of a shoe, or an operation for ingrowing toenail. The pain is very severe and has a bad influence on the general condition of the patient. Mummification is not characteristic of arteriosclerotic .gangrene. 388 I'lTll Ol- I'KOCRESSIVE LITERATI Kli. [New YoiiK Medical Purchase Serevent Online Jol'bsal. though it is more comnioii llian the moist variety. Prophylactic and conservative measures are in- dicated, hence it is important that the condition should be recognized early. Conservative treat- ment consists of rest in bed, the internal adminis- tration of potassium iodide, elevation of the limb, and the application of ointments when ulcers are

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