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pital, May 13, 1914. thickened condition of the tympanic membrane may be sufficient to resist the suppurative process in the tympanic cavity. In fact, cases have come to opera- tion in which middle ear and mastoid viagra promotion disease has been complicated by intracranial and sinus disturb- ances without the drum membrane viagra promotion ever having ruptured or the ear having discharged. Mastoid abscess also may occur a long time after a suppu- rating ear has apparently healed and the discharge has ceased. In such cases some infective focus has remained quiescent in the mastoid cells. These atypical cases of mastoiditis are the bane of the otologist. With the absence of all definite signs the disease may extend and produce marked destruction of tissue, symptoms not showing until the inflam- mation has invaded vital structures, giving rise to labyrinthitis, meningitis, brain abscess or sinus thrombosis, or has viagra promotion progressed outward with the formation of a subperiosteal or a Bezold abscess. In these cases, therefore, early diagnosis is urgent. In primary mastoiditis the inflammation begins in the comprar viagra en argentina mastoid bone and may show definite symptoms. It differs therefore from atypical or viagra promotion symptomless mas- toiditis in which the infection has proceeded from the middle ear and in which objective signs comprar viagra en argentina are wanting. In my service at the People's Hospital I have lately operated upon two cases of primary mas- toiditis. Case I. — M. B., three months old, seen March 10, 191.3, showed a large swelling behind the left ear. The mother stated that the child had received a sharp blow on the left side of the head a week before. The tym- comprar viagra en argentina panic membrane and the auditory canal were normal in appearance. The case looked like a typical subperi- viagra promotion osteal abscess. No history of measles, scarlet fever or diphtheria. No tubercular or specific dyscrasia. Ears all right previous to this trouble. A slight increase in temperature, pulse, and respiration. Blood examina- tion gave a slight leucocystosis with a moderate poly- nuclear increase. comprar viagra en argentina A preliminary paracentesis was negative. On operating, the first incision through the skin and periosteum freed profuse thick pus. There was necrosis of the bone with involvement of the an- trum. The entire mastoid cavity was cleaned out and then packed. Healing was rapid. The infection here probably was through the lymphatics, irritation of the periosteum being followed by inflammation with exten- viagra promotion sion and viagra promotion involvement of the bone. The case is of in- terest as showing the development of mastoid abscess following traumatism, together with comprar viagra en argentina the absence of local evidence of middle ear disease. Case II. — Y. S., seven years old, comprar viagra en argentina seen April 13, 1914, presented a left retroauricular bulging. The mother had noticed the swelling for five days previously and could assign no reason for it. A careful examination failed to elicit any connection with the middle ear. There was viagra promotion a very slight haziness of the drum, but the markings were clear, and no congestion or bulging was visible. There was no swelling in the canal wall or any furuncular condition. Functional examination showed some impairment as compared with the other ear. There was a history of frequent attacks of ton- sillitis and chorea. On operating a general destructive process was noted, necrosis involving the tip, the zygo- matic and perisinus cells. Examination of the mastoid pus showed a coccus with a tendency to form small chains comprar viagra en argentina viagra promotion similar to the coccus often noted in tonsillar inflammation. The source of infection here probably was the tonsil, the infective agency passing through without involving the eustachian tube and middle ear into the antrum, in which lodging in a mastoid cell, it is walled off from the tjTiipanic cavity by inflammatory closure of the aditus. In postauricular cases without local s\Tnptoms in- dicating middle-ear disease careful examination is necessary. Mastoid tenderness and pain may be due to abnormal or functional postaural nerve con- ditions. Furuncle of viagra promotion the canal is a common cause of swelling of the skin back of the ear. An inflamed September 18, 1915] MEDICAL RECORD. 483 condition of the mastoid glands may closely simu- late mastoiditis. These anomalous viagra promotion cases demand prompt and e.xact recognition in order to avert seri- ous consequences, and all aids including transillumi- nation and radiography should be utilized. 221 Second Avenue. A CASE OF INTENSE FOOD ANAPHYLAXIS. Br LOWELL C. FROST, M.D., LOS ANGELES, comprar viagra en argentina CAL. The following case of food anaphylaxis is so typ- ical and clear cut in its symptoms and so intense in its manifestation, as, I believe, to merit pres- entation. I was called by telephone at 7 p.m., June 2, to see a patient who was reported to be suffering from very acute indigestion. On arriving at the house twenty minutes later I found the condition as follows : The patient, F. K., a well nourished young woman of about thirty, was in bed in a comprar viagra en argentina semi-recumbent posture. The skin over the entire body was bright red with an intense erythema, except the lips and finger nails, which comprar viagra en argentina were somewhat cyanotic, and the eyelids, upper