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modification in the operation. In certain cases chole- dochtomy is the cheap viagra spray choice operation, but it is always difficult, frequently dangerous, and sometimes im- possible of practical execution. Dr. Donald Maclean, of Detroit, in discussing Dr. Dunn's paper, said that the surgery of the gall bladder is only in its infancy, but there viagra price coupon is always the hopeful and inspiring feeling about operations on the gall bladder that if the patient be saved from great pain and great danger there is everything to be cheap viagra spray grati- fied about viagra price coupon and nothing to regret. Dr. Alexander Hugh Ferguson, of Chicago, said that the great question is, When shall we operate? It we examine the gall bladder and find it enlarged so that there is apparently a tumor, it is the time to oper- ate. If the stone be a small one, it may pass through, but if not, it may force its way into the common duct, where it becomes impacted. Cases of one stone are more difficult than those of several stones, and the side of the gall bladder is no indication. viagra price coupon If the pa- tient has colic and jaundice, it is imperative to open the gall bladder and not to wait until the development 74Q MEDICAL RECORD. [May 23, 1896 of pyrexia. By suturing together the gall bladder, peritoneum, and skin, thirty-three per cent, of the cases have resulted in permanent fistula. In view of the fact that jaundice cases stand operation and chlo- roform very badly, we should operate as little as pos- sible. As soon as we see bile, our work is finished. There are two ways of getting at the common duct, one internal and the other external to the duodenum, of which the former is the better. If there be jaun- dice, the incision should be either oblique or trans- viagra price coupon verse; the oblique gives the more room. In order to tell whether or not the common duct is patulous, a good way is to take a glass tube that is bulbous at one end with a rubber bulb attached to the other. This will become impinged into the duct. If water will then rlow through the bulb it is well to stop operating. Dr. J. C. Oliver, of Cincinnati, asked what was found to be the cause of death in the case of the young woman to whom Dr. Dunn had referred as hav- ing had two attacks of biliary colic without jaun- dice. Dr. Hunter McGuire, of Richmond, said he be- lieved that some day a method will be found of dis- solving gall stones, so that operation will not be necessary. Dr. Dunn said that the young lady referred to by Dr. Oliver died of exhaustion. He was of the opinion that too many men have the idea that in these cheap viagra spray cases there should be jaundice, or tumors or colic viagra price coupon resem- bling the pains of childbirth. What is wanted is more diagnosis and less technique. In none of his cases had he found tumefaction, unless by this is meant enlargement of the liver dulness which is fre- quently present. Operative Interference in Abdominal Ailments. Dk. Donald Maclean, of Detroit, reported several cases bearing on this question. In opening his paper he stated that he desired to raise the question of the advis- ability of interference or non-interference in cases of abdominal ailments, traumatic or otherwise. The first case mentioned was that of a very obese woman of fifty, who had suffered from absolute obstruction of the bowels for ten days and was in a very viagra price coupon advanced state of exhaustion. Upon opening the abdomen, after a somewhat prolonged and careful examination, a large egg-shaped calculus was found, and the intestine cheap viagra spray both above and below was so constricted that it constituted a perfect obstruction. Although the abdominal cavity was closed with all possible speed, the patient died in twelve hours. The second case was that of a man who gave the history of several well-marked attacks of appendicitis, but who was apparently quite well ami engaged in active manual labor when he came for ad- vice, complaining only of a feeling of weakness in the right iliac region. Operation was advised, and the appendix was found distended with pus. On further investigation extensive intestinal adhesions were en- countered, and it was found cheap viagra spray necessary to sew up sev- eral large rents in the intestinal walls produced by disentangling these adhesions. Patient made a com- plete viagra price coupon and rapid recovery. The third ease was that of a young man cheap viagra spray of nineteen, who had had repeated attacks of appendicitis. He was a health)' and robust fellow, and on this account postponement of operative inter- ference was advised, but the speaker was compelled the following day to change his opinion absolutely, as the patient was found in a very different condition, with tongue furred, pulse [20, and temperature ioi' I''. Operation was then advised, and the appendix was found deeply embedded in an immense inflamma- tory mass which surrounded the Caecum. The fourth case was that of a man who was taken suddenly and violently ill cheap viagra spray with all the signs of appendicitis, and when first seen by Dr. Maclean the patient was in a state of great distress from constant cough, with viagra price coupon e\ sive expectoration of an indescribably fetid character. The temperature was high, pulse rapid, and there was a total loss of appetite with proportionate general weakness. The burrowing of an appendicitic abscess behind the peritoneum was suspected, and an incision was made between the sixth and cheap viagra spray seventh ribs on the right side, which fortunately tapped the depot of fetid pus. Three years have elapsed since the operation, but when seen recently the patient presented the very picture of manly health and vigor. The fifth case was that of a man, thirty-five years of age, who was thrown from his bicycle and alighted on the asphalt pavement