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DUODENAL ULCER. By J. -AL Lynch, M. D., Xew York. There can be no question as to the frequency of ikiodenal ulcer. The symptoms are know n to gambling sites with free money every ]rractitioner of medicine. To the surgeon, however, particularly such men as Moynihan, of Leeds, and the iNIayos, of Rochester, belongs the credit of hav- ing elucidated it. Moynihan, in his work on Ulcer of the Duo- denum, gives such a lucid exposition of the subject that it would seem as though one needed only to read his book to make an accurate diagnosis in the first case that came before him. That was my own impression till my experience with the case given below. We are all familiar non gambling casino games with the fact that chronic ap- pendicitis is frequently a factor in free pc gambling games download spasm of the py- lorus, so that in a case of chronic dyspepsia we rarely accuse the gambling slot machines win stomach until after we have elimi- nated the appendix and gallbladder. But if the pain and other symptoms are entirely confined to the ap- pendix, this organ is usually tried by drumhead court martial and found guilty. Case. Mrs. M. ; age, thirty ; married ; no children. Family history : Father died at sixty-five, of apoplexy ; mother living, healthy. Brothers and sisters all healthy. Habits : Patient drank tea, coffee, and alcoholic liquors in moderation. Smoked six cigarettes free online casino gambling slots daily. Diseases of childhood : Measles and scarlet fever ; no complications. Past history : Patient had been perfectly well up to five years ago when she had wliat was evidently an acute in- flammatory process of the uterine annexa. Since then she had suffered more or less from constipation. The present trouble dated back to February, 1909, and following a rath- er constipated movement, she had an acute pain in the anus ; the pam was so severe that she was given morphine to relieve it Following this, she was fairly comfortable until the next movement, when she beg:an to have severe pain radiating down the legs and to the back ; she con- tinued \\\ this condition for several weeks, having pain every lime the bowels moved ; but by means of supposi- tories and laxatives was fairly comfortable. Following this, her constipation became worse and owing to the pain that accompanied it she went to the toilet only once in two days. In May, online gambling free money no deposit 1909, she was referred to mc. She was a woman of thirty, rather stout, but anemic. Examinations of the heart and lungs were negative. Ab- dominal examination revealed nothing unusual, except some tenderness over the appendix. Vagina] examination : Uterus retroverted and rclroflexed. A good deal of thickening over the left tube, which was bound with a mass of adhesions to the sigmoid. The right ovan,' was prolapsed, enlarged, and fixed in the posterior cul-de-sac. Rectal examination: The sphincter spasmodically con- tracted. There was an anterior sentinel pile ; above this could be seen a well gambling bonus club net entertainment free casino games developed fissure. Examination was so painful that no online gambling free casino games further effort was made to explore the rectum at this period. Local applications to the fissure gave the games gods and gambling free download patient great relief and in a short time it free gambling slots machines was entirely healed. A proctoscopic examination revealed atrophic, catarrhal condition of the rectum and lower portion of the sigmoid. .Above this it was impossible to pass the proctoscope on account of an acute angulation of the sigmoid, evidently due to an adhesion to the left tube. Three months afterward I was called to see this patient with a recurrence of the fissure, severe pain over the ap- pendix, exquisite tenderness on pressure, and all the class- ical symptoms of appendicitis. A diagnosis of acute ap- pendicitis was made and the patient advised to have an operation performed. That evening play gambling games for free she passed" a lot of dark clotted blood and fsecal matter; subsequently she had a number of movements, dark in color, and containing large quantities of digested blood. An examination of the rectum under nitrons oxide gas revealed nothing except what has already been stated. Next morning the patient was given a Boas-Ewald test breakfast. Macroscopical : Large quantity of liquid with very little solids. Microscopical : Starch, yeast, and a few epithelial cells with fat globules. Chemical : Free hydrochloric acid, 70 ; combined acids, J4; total acidity, 90; lactic acid, a trace; starch digestion, poor. Here was a patient who until she was cross examined gave no history of any disturbance of digestion. Her pain was all referred to the gambling slot machines region of the appendix, and the tenderness was confined to the same region. Later on, I elicited the fact that she suffered off and on from what she called indigestion; that she occasionally had pains coming on some four or five hours after eating: took something for relief, vomited, and felt better after it. The case we have related proved ver\- instruc- tive, and in looking over the histories of a num- ber of cases we can now recall several that were undoubtedly cases of duodenal ulcer. We have also seen several cases subsequently, but the symptoms were not confined to the appendix, and gambling slot machines online a diagnosis of ulcer could have been made from the history. A point worth mentioning is the fact that the paira seems to be most intense just previous to the haem- orrhage, list gambling board games subsiding, subsequently, by lysis. We pub- lish this case in the hope that others will not be taken unawares, as we were, and that in cases of appendicitis a careful history of the patient's di- gestive apparatus will avoid the error into which we were led. The two conditions which are most apt to be con- founded are spasm of the legal online sports gambling sites pylorus, due to the free gambling games no deposit chron- ic appendicitis, and duodenal ulcer, with all the .symptoms referred to the appendix. A carefully taken history will clear up the diagnosis, as every case of duodenal ulcer has a clear cut hi.story. 58 West Fifi y-eighth Street. THE IMPORTANCE OF NASAL BREATHING. By A. Emil Schmitt, M. D., New York. Instructor in Operative Surgery, Medical Department, Columbia University. For several years past much attention has been given to the importance of the removal of super- abundant adenoid tissue, which is looked upon as the causative factor for all ills which really are due to defective nasal breathing and without a concep- tion of the card gambling games list true relation of the various factors involved. I will here dwell particularly on the great importance gambling slots for dummies and marked influence of air pres- sure upon the internal structures of the nose during normal breathing and the serious consequences which result when nasal breathing is not persisted in. A person breathing constantly through the nose has nostrils of sufficient size to accommodate a volume of air to expand the lungs to their full capacity. Vibrissa are present to keep out tlie gross particles of dust. The nasal fossre within show a sufficient height with a low floor correspond- ing -to the properly flattened palate, and the lateral walls are puslied sufficiently far play gambling games online for free out to give roomy fossae on either side of the septum. Where a devia-

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