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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