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conservative spirit which he manifests, disarms criti- cism. Dr. John A. Wyeth in the same issue reiterates his statement that " appendicitis is strictly a surgical le- sion." The appendix, according to modem teaching, is a rudimentary herbivorous stomach. If we can have catarrhal gastritis, phlegmonous gastritis, gastric erosions, and gastric ulcers which m: y perforate an ! cause subphrenic abscess, local and gtneral peritoni- tis, then gastric catarrh and gastric ulcer are surgical diseases, the treatment of which no physician should undertake without an operative surgeon at his elbow. Dr. Wyeth quotes me as saying that " there is ncr peritonitis in the fulminant cases," and the statement thus appears in my article. A reference to the orig- inal draft of my article would show this to be an error either in copying or in the typesetting wherebv a qualifving word was omitted. Taken in connection with what precedes and follows the quotation referred to, I think my meaning must be clear, and Dr. Wyeth will perhaps find it stated more lucidly in conclusions 3d and 4th. " That the proper treatment in non-oper- generic aricept viagra ative cases is to favor the formation of plastic exudate and to secure firm adhesions: that the dangerous cases- are the fulminant cases in which no warning perito- nitis exists." By a warning peritonitis, I mean the lo- calized plastic peritonitis which usually precedes per- flation, not the general peritonitis which may follow it. Any physician worthy of the title knows that a diffuse septic peritonitis generic aricept viagra follows in the fulminant cases, but this is far different from the conservative, adhesion-forming, localized process of which I was writing, and which I believe to be not '"the result of blind chance," as Dr. Wyeth terms it, but the delib- generic aricept viagra erate effort of nature to wall in the diseased part. In certain cases, for some reason not fully understood, no plastic exudate is thrown out around the diseased appendix no preliminary peritonitis generic aricept viagra and then we have, if perforation or gangrene occurs, a fulminant case. I trust that this is sufficiently lucid for the brand viagra suppliers av- erage comprehension, for I hardly like to rest under the imputation that I have never seen, read, or heard of a septic peritonitis following perforation of the bowel. Dr. Wyeth feels sure that I "erred in my diagno- sis." He also states that '' a surgeon of ripe experi- ence or a physician generic aricept viagra of equal experience can tell in the vast majority of instances when operation is indi- cated." Contrast these two statements. The diagno- sis is not ordinarily considered extremely difficult, while the question of operative interference is often one which will tax the best judgment. I trust Dr. Wyeth did not intend to be discourteous. It is perhaps regrettable for the sake of argument that no autopsies were held, no laparotomies per- 820 MEDICAL RECORD. [June 6, 1896 brand viagra suppliers formed, that the fluoroscope had not then been per- fected, and that therefore I cannot prove my case. Inasmuch generic aricept viagra as it is not considered strictly ethical to enlarge upon one's own diagnostic skill beyond a certain limit it will be readily seen that Dr. Wyeth has me on the hip, or to quote from that classic work, "Decius Repetita Placebit," published by a certain chemical company, " he gat him the bulge on me." I'll is question of diagnosis is after all merely a matter of opinion, and would mildly suggest that his absence of knowledge of my cases, and of my own ability or lack of it, detract somewhat from the value of a state- ment which coming from a man of his reputation would otherwise have more weight. He refers me also to a paper or rather to an ab- stract of a brand viagra suppliers paper by Dr. Samuel Lloyd, giving a mortality of seventy-seven per cent, in cases treated generic aricept viagra by medical means. brand viagra suppliers In the absence of any informa- tion as to how many of these generic aricept viagra cases obviously required operation, how many were treated symptomatically, by salines, by the various other methods, or mis- treated, and with no reference in the abstract referred to as to generic aricept viagra the proportion treated by opium, given, not empirically, but with the view of favoring the de- velopment of localized plastic peritonitis, the compar- ison is obviously unfair. The doctor thinks it probable that the proportion which recovers under so-called conservative manage- ment would number about fifteen in every hundred. The vision of the operative surgeon is liable to be distorted by the fact that the graver cases are referred to him for operation, while the mild ones are likely to escape his observation. The article was written not as a protest against the operative treatment of appendicitis, but as a pro- test against indiscriminate operating. I believe that nothing in it can be so construed as to interfere with operative procedures in any suitable case. Certainly, some of my own cases would have been operated on, had circumstances been favorable. Our text-books are largely written by hospital men from the hospital standpoint. This is in one sense a necessity, but it would be wise for " those in authority," before laying down cast-iron rules that all or even the vast majority of cases should be operated on, to remember that these text-books are read and taken as guides brand viagra suppliers in the country as well as in the city, and that dogmatic statements, sweeping assertions, are not only capable of doing an immense amount of harm, and of distinctly increasing the mortality, but seriously impair and discredit the surgical side of the discussion. Recklessness of Statement implies necessarily an equal recklessness in the selection of cases for operation, and a large num- ber of letters now brand viagra suppliers on my office table, from practi- tioners living generic aricept viagra in many localities in this country, would indicate that a reaction from the extreme views held