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587 them were alive when lost track of. The prognosis was so grave that early diagnosis must be followed by prompt operation even at considerable risk. Empyema must be thoroughly drained to avoid the danger of lung viagra not covered by insurance involve- ment; after this occurred surgery rarely offered viagra not covered by insurance any assistance. Dr. Henry Sewall spoke of the difficulties encoun- tamsulosin and viagra tered in making a diagnosis of subphrenic abscess and said he would have to confess to having made tamsulosin and viagra many miscalculations in diagnosing the condition. He be- lieved it was overlooked ninety-nine times where it was recognized once. Dr. John A. Lichty of Pittsburgh said his experience has been somewhat different from that of Dr. Hall. In about 700 cases of appendicitis he had not found sub- phrenic abscess more than five or si.\ times and in only one instance did he find an empyema and that ruptured into the lung. Dr. Philip King Brown of San Francisco said he had just had an e-xperience with two cases that answered this question. One had been operated on for a para- nephretic abscess and had a viagra not covered by insurance streptococcic septicemia and pleurisy, and very striking friction rales were percep- tible. The other was a deep abscess of the liver which was accompanied by a pleurisy on that side of the lung. Bevan had pointed out that in acute appendicitis viagra not covered by insurance pleurisy of the lower right portion of the lung was not uncom- mon, though there was no lymphatic connection to e.x- plain the association of the two conditions. Dr. Hall, in closing the discussion, explained that the reason he had found these subphrenic abscesses more frequently than some others was because of the fact that he lived in a more sparsely settled country where it was improbable that a person suffering with such a condition would find a viagra not covered by insurance physician who would be able to make the diagnosis. Another reason for finding the condition more frequently was viagra not covered by insurance that patients were not so likely to be operated on early for the conditions that might produce subphrenic abscess if neglected. He re- lated that three cases seen in succession in which the subphrenic abscess was due to appendicitis all had deep cavities just above the diaphragm; these were of the neglected type and one would not see them in a large city. That was the reason he tamsulosin and viagra had insisted on early operation because ninety-nine per cent, of the trouble was due to neglect and showed what an neglected ap- pendicitis could do. In reply to the question as to whether these abscesses perforated more frequently than empyema, Dr. Hall said he thought the subphrenic ab- scesses perforated oftener than empyema because em- pyema was more likely to be recognized and treated. viagra not covered by insurance The Acute Infections in Diabetes Mellitus. — Dr. John A. Lichty of Pittsburgh, Pa., presented this communi- ation. He stated that from the beginning of their knowledge of diabetes mellitus as a clinical entity, it had generally been recognized that patients suffering Lrom this malady were poor surgical risks and many theories had viagra not covered by insurance been advanced to account for this fact. One of these theories was that tamsulosin and viagra there was a disturbance of tissue vitality due to the existing hyperglycemia and on account of this disturbance bacterial invasion occurred tamsulosin and viagra more easily. This view had been largely substantiated by Dr. J. C. DaCosta and Dr. E. J. G. Beardsley in the clinical laboratory of the Jefferson Medical College Hos- pital. There was very little in the literature, however, that would lead one to think that the ordinary infections which were included under medical diseases were par- ticularly fatal in patients having diabetes mellitus, with perhaps the exception of erysipelas, lobar pneumonia, and pulmonary tuberculosis. It was the author's pur- pose to show that the more simple and ordinary infec- tions were not infrequently a determining factor in influ- encing the mortality of diabetes. The writer reported two cases of diabetes in the first of which an acute in- fection of the nasopharyngeal mucous membrane was followed by an acute otitis, and in the second a cold in the head was the starting point of a train of sjTnptoms which speedily led to a fatal termination. He said he might mention other instances of similar apparently mild infections and some of the graver infections, such as lobar pneumonia and acute pulmonary tuberculosis, but they all showed the same rapidly fatal results. It was found that when the restricted carbohydrate diet upon which the patient usually maintained his weight and feeling of well being was relaxed and an attempt made to force upon him a large amount of general diet, as was usually done in pulmonary tuberculosis, the amount of sugar eliminated invariably tamsulosin and viagra increased and the che=;t signs became rapidly alarming. On the other hand, if the urine could be kept sugar free or nearly so and the caloric value of the diet could be maintained at the normal or slightly above the normal requirements, other things being equal the patient invariably im- proved. This observation has been made so viagra not covered by insurance often that it had led the writer to apply the same principle in the treatment of the acute infections in diabetes mellitus. That was, no matter how grave or apparently trivial the infection might be, the consideration of the diabetic element in the case was of paramount and viagra not covered by insurance extreme im- portance. Of 33 fatal cases oi the writer's own series, eight died of some acute infection. This included cases of pulmonary tuberculosis and lobar pneumonia. Sta- tistics which the author had collected from Joslin Jane- way, and Friedenwald showed that about one-third of all the deaths were either directly due to or hastened by the acute infections. This fact should lead one to warn his patients suffering from diabetes mellitus against the dangers of infections, and to instruct them properly in tamsulosin and viagra prophylactic measures. It also suggested the necessity of extreme care in treating these cases even though the infection seemed the mildest and most innocent. Dr. F. M. PoTTENGER Said he had had the same ex- perience as the writer of the paper in diabetes mellitus in tuberculous patients. He had found that about one- half the patients on an ordinary diet lost their sugar temporarily or for a period of months. He related the instance of one patient who had been sugar free for