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diabetic coma and died from heart failure. The au- topsy showed extensive infarcts in the pancreas and multiple points of fat necrosis in the omentum. These were of fatty crystals, so that the omentum presented the appearance of a cloth sewn with bright stars. Stadelmann regarded this as a case of diabetes acutis- simus, for it had without question begun only a week before, and he thought the generic viagra guidelines disease of the pancreas should be referred to an infection. After complete- destruction of the pancreas the diabetes set in and caused the death of the patient. Litten, to whom we owe the so-called diaphragm phenomenon, recently presented a communication to the Verein fiir innere Medicin regarding a physical sign in the larger arteries of pathological and diagnos- tic significance. Starting from the well-known fact that an arterial murmur may be caused by pressure upon the trunk of an artery, he asked himself what phenomena corresponded to this murmur, if the pulse corresponded to the tone, or what perceptible move- ments of the arterial wall can be called forth by com- pression. He could perceive a murmur in all the larger arteries from the diameter generic viagra guidelines of the aorta to that of the radial as an expression of the unknown symptom. The sign can be appreciated, however, generic viagra guidelines only after a certain measure of experience, but makes an generic viagra cvs extraor- dinary impression upon the observer. The phenome- non is best observed in the subclavians and the ab- dominal aorta when the latter, as in enteroptosis, is easy of access. The method generic viagra cvs of examination is the fol- lowing: With one finger light pressure is made on the artery while the palpation is made with a finger of the other hand. In pathological conditions, in cases of diseases of the arterial system, this murmur takes on a blowing character. These affections are those in which there is generic viagra guidelines an increased blood generic viagra cvs pressure and dila- tation of the arterial system, such as aortic insuffici- ency true or false, Graves' disease, arteriosclerosis, poisoning by amvl nitrite. In these affections the symptom is very strongly marked, and may even be felt in the smaller arteries of the generic viagra guidelines foot. Of especial prac- tical value is generic viagra cvs it in the diagnosis of sclerosis of the as- cending and abdominal aorta. Litten reported two cases of disease of the abdominal aorta, in which the diagnosis was materially aided by this symptom. The first case was one of nervous and very painful palpita- tion, and here only the usual murmur caused by com- pression of an artery could be felt. In the second generic viagra cvs case the phenomenon was very marked, and this, added to the almost uncontrollable pains in the abdomen, permitted of a diagnosis of sclerosis of the abdominal aorta to be made. The correctness of the diagnosis in each case was shown later at the autopsy. The author also presented some patients in whom the symptom was very beautifully shown. At the last meeting of the Berlin Medical Society generic viagra cvs Blasko reported a case generic viagra guidelines of leprosy and read a paper upon the prevalence of generic viagra guidelines this disease in Germany. The case was one of anaesthetic leprosy in a fifteen-year-old girl from the eastern part of Prussia. There is at present in German medical circles an agitation generic viagra guidelines on foot for the establishment of a recognized and authoritative medical court of honor. This court would have jurisdiction over physicians only in what concerned their professional conduct, and not in the ordinary affairs of life. IS APPENDICITIS A MEDICAL OR A SURGI- CAL LESION? To the Edjtdr of the Medical Record. Sir: The article by Dr. MacArtney, " Appendicitis from the Medical Standpoint," in your issue of May 2d, and the letters from Drs. Morris and Wyeth in your issue of May 9th in reply thereto, are intensely interesting to the active practitioner, and present very clearly the medical and also the surgical side of opin- ion on the treatment of this frequent and dangerous disease. I believe all three of these gentlemen are truthful in their statements of facts as they have observed them, and sincere in the opinions which they have ex- pressed, but it is evident that they cannot all of them generic viagra cvs generic viagra cvs be correct in the positions assumed, and that some fur- ther explanations are needed to make the truth appear. Dr. MacArtney has described in an admirable man- ner a line of treatment which seems to me to be sen- sible, which in his hands has certainly been success- ful, and which, it appears to me, is consistent with our present knowledge of the pathology of appendicitis. It is almost identically the treatment which I have fol- lowed for the last twenty-two years, with the same measure of success as is reported by Dr. MacArtney. I have kept notes of but a few of my cases and cannot tell just how many I have treated, but it has been more than the twenty-four reported by Dr. MacArtney. Some of these cases have been very severe, attended by great pain and high temperature, and several times a distinct tumor has been felt in the region of the appendix". None of my patients died, all made good recoveries, and only two were operated upon one recently for re- curring appendicitis (six attacks since last October), and one in a neighboring city, whom I saw but three times, developed an abscess which pointed and was opened near McBurney's point. It is evident that our surgical friends, Drs. Morris and Wyeth, have never tried the medical treatment recommended by Dr. MacArtney. If they will care- fully try it in the next twenty cases, from the very commencement of the primary attacks, they will find very few instances in which an operation will be needed. In order to accomplish the best results, this generic viagra cvs treatment should be intelligently applied from the commencement of the disease. It is implied in Dr. Wyeth's letter that he did not believe the physician who stated, at a meeting of the American Medical Association, that he had treated