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necessary to supplement the treatment by the admin- istration of a nasal spray of sodium bicarbonate solution. 7. The Appendicular Liver. — R. N. Duffy viagra coupons printable discusses this subject under two headings: (1) toxic hepatitis and (2) suppurative hepatitis. Soon after the onset of appendicitis, as early indeed as the second or third day, toxins elaborated in the appendix viagra coupons printable may make their way to the liver, mainly via the portal route, and there set up a toxic hepatitis. This condition was first described most clearly by Dieulafoy in 1898. A day or two after the onset of the abdominal pain in appendi- citis, it may be noted that the patient is slightly jaun- diced. The jaundice is rarely deep, and is usually lim- ited to the conjunctivEe and the skin of the face. Its onset may make one doubt the original diagnosis and think of gallbladder and bile duct involvement. How- ever, it is found that the tenderness is not over the gallbladder, but at McBurney's point. The liver is very rarely enlarged and palpation elicits practically no tenderness along its margin. The urine in these cases is of a dark reddish-brown color, suggesting the pres- ence of bile. As a matter of fact, true bile is usually not viagra coupons printable present. When tested with fuming nitric acid the characteristic green and yellow rings professional viagra ceep of biliverdin and bilirubin cannot be seen as a rule, but a brownish disc is evident at the line of contact. Further tests prove this to be due to urobilin. The urine may further show a dMinct trace of albumin and renal casts will be found in the sediment. These findings usually indicate a severe grade of appendicular inflammation ; especial- ly is this so if albumin and casts are present in the urine. The patient's sjTnptoms may be all the while deceptively mild. Suppurative hepatitis, consecutive in the vast majority of cases to suppurative pyelophlebitis. The sjTiiptoms of toxic hepatitis develop early. The professional viagra ceep SjTnptoms of suppurative hepatitis are later in their full development although the process is comparatively early professional viagra ceep in its viagra coupons printable inception. It is the product of microbic ac- tivity in the portal ramifications and the liver sub- stance, whereas toxic hepatitis is due to the action of toxins alone. The picture is entirely different. Where- as toxic hepatitis is not associated with pain in the 412 MEDICAL RECORD. [September 4, 1915 region of the liver and the liver is not enlarged, as a rule; suppurative hepatitis, on the other hand, is as- sociated with great pain in the hepatic area and marked enlargement of the liver. Suppurative hepa- titis following appendicitis has its onset never earlier than the fifth or sixth day after the beginning of the appendix inflammation. It may follow an apparently mild attack. The patient may seemingly be convalesc- ing well. There may be practically an entire subsi- dence of pain and elevation of temperature, a stage of "treacherous calm." The appendix may have been re- moved, say on the seventh or eighth day after the on- set viagra coupons printable of the attack, but viagra coupons printable the mischief may have already started professional viagra ceep in the portal vein and then the appendectomy is futile. The chills occurring in this condition are most violent and the temperature rises high. The sweats are drenching. The liver enlarges rapidly and the en- largement may become enormous. The right lobe is usually more involved than the left. The spleen viagra coupons printable shows no enlargement. There are great hepatic and epigas- tric pain, much nausea, and vomiting, and diarrhea is quite a frequent complication. Jaundice may be early or late, slight or intense; the urine usually contains bile, albumin, and casts. The general symptoms are typhoidal, the tongue is dry and red. Practically all of the cases are fatal. Journal of the American Medical Association. August viagra coupons printable 21, 1915. 1. Benign Lesions of the Stomach and Duoflenum. The Choice of Surgical Procedure with Special Reference to Late Results. C. H. Peck. 2. Chronic Deafness : The Present Status of Its Treatment D. H. Walker. 3. Subinfection from Foci in the Pelvis and Abdomen. H. G. Wetherill. 4. The Hospital Interne Tear as a Requirement for Medical Licensure. J. Ewing. 5. Intestinal Obstruction. A. McGlannan. €. Mental and Physical Survey of Supposedly Normal Chil- dren. L. Porter, A. Huftaker and A. Ritter. 7. Rumination in Infancy. A. Strauch. 8. Operation on the Hypophysis According to Hirsch's Method. Presentation of a Case with Brain, Eye and Other Symptoms. E. C. Sewall. 9. Congenital SsThilis in the Light of the Wassermann Re- action. D. J. Glomset. viagra coupons printable 10. Report of Four Cases of Meckel's Diverticulitis. G. K. Strode. 1. Benign Lesions of Stomach and Duodenum. — By C. H. Peck. (See Medical Record, June 26, 1915, page 1092.) 3. Subinfection from Foci in Pelvis and Abdomen. —